Consent to Treat Minor Patient Without Parent/Legal Guardian Present

By law, any child under the age of 18 years old cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.

Minor's Name

DOB

For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child:

Name

Relationship to Patient

Name

Relationship to Patient

Limitations:

Identify any specific limitations on the kinds of medical services for which this authorization is given. (If none, state “none”)

Check here if you wish to give consent for the minor to receive medical care without an accompanying adult. This consent may only apply to minors age 16 and older.

This consent shall be in effect for:

This date only:

Date

Indefinitely, until revoked by written communication

Authorization

I, (legal parent/legal guardian name)

request and authorize Lakeside Dermatology and its personnel to deliver medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor child. I am also aware that my child may have a balance, copay, coinsurance and/or deductible that is due at the time of their visit. I agree to send my child to the office prepared for payment, at the time of service. If my child is not prepared, I understand that the appointment may need to be rescheduled.

I have the legal right to preauthorize Lakeside Dermatology and its personnel to deliver medical treatment and services to my child. Medical care and interventions may include, but are not limited to: medical evaluation, physical exam, injections, lab work, etc. (example: swabs, blood draws, biopsies, liquid nitrogen, electrocautery, etc.)

I have read, understand, and give my consent as stipulated above. My signature (electronic or printed) means that I have read this form and/or have had it read to me and explained in the language that I can understand.

Parent or Legal Guardian Signature

Relationship

Date

DISCLAIMER: By signing 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.