FDL MINOR CONSENT

FDL Informed Consent for Medical Treatment of a Minor Patient

Patient Name:

Patient Date of Birth

NOTICE:

All minors seeking medical treatment for dermatology care with FDL must be accompanied by a parent/legal guardian during the first office visit. After the initial appointment, a minor may be seen for treatment without being accompanied by a parent/guardian/authorized adult only under the conditions specified below.

CONSENT AND DIRECTIONS:

I understand that under Virginia law, a parent/legal guardian/authorized adult must provide consent to medical treatment of a minor. A minor is a person under the age of 18 years old who is not emancipated by a court.

I acknowledge that I am the parent/legal guardian/authorized adult of the minor child (“Patient”) and certify that I have the legal right to consent for medical treatment for Patient identified above and hereby authorize FDL to provide medical treatment as indicated in this form.

If I am not available, I also acknowledge and certify that the following persons are also legally authorized to consent to treatment of the patient by FDL as provided in this form, including but not limited to signing any additional consent forms and/or accompanying the Patient to appointments as may be needed:

Name

Relationship to Patient

Name

Relationship to Patient

If a parent/legal guardian/authorized adult cannot attend the appointment, I consent to FDL providing treatment in accordance with the following instructions that I have selected by circling yes or no on each of the following items:

I require that all treatment must occur in the presence of a parent/legal guardian. I do not want the Patient in my care to be seen at all in my absence.

Yes No

I authorize FDL to re-fill prescriptions for the Patient as deemed necessary for treatment.

Yes No

I authorize FDL to treat a new diagnosis under the condition that FDL obtains verbal consent from a parent/legal guardian before the new diagnosis is treated.

Yes No

I authorize FDL to write new prescriptions for the Patient as deemed necessary for treatment.

Yes No

I understand that some medications require that bloodwork and/or a pregnancy test be complete before prescribing/refilling. In cases where such testing is required, I understand that a parent/legal guardian/authorized adult must be present for such testing. The presence of such adult shall indicate consent to the testing unless otherwise stated.

I understand that some procedures performed by FDL may require a separate consent form. I further understand that any procedure performed by FDL that requires that a separate consent must be signed by a parent/legal guardian/authorized adult prior to the procedure.

I acknowledge and agree that I have been given an opportunity to ask questions regarding treatment for the Patient and had those questions answered to my satisfaction prior to signing this consent form.

I understand that this consent will be valid for 12 months from the date signed unless sooner revoked.

I acknowledge and agree that my consent to treatment of the Patient has been provided voluntarily in accordance with the information provided above.

Parent/Legal Guardian/Authorized Adult Name (printed):

Relationship to Patient:

Parent/Legal Guardian/Authorized Adult Signature

Date

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.