AUTHORIZATION FOR TREATMENT OF A MINOR

I, the undersigned parent/legal guardian, of the minor person listed above do authorize the physicians Dr. Alan Levy, Dr. Danielle Levine, Dr. Julie Jefferson, Dr. Meredith Wagner, and Dr. Josh Cash and Advanced Practice Providers (APP) Lauren Plyler, NP, Dallas Provence, NP, Jade Wilkie, NP, Barry Flippo, PA-C, Jodi Burgess, PA-C, Megan Philips, PA-C, Susannah Cash, PA-C, Denise Shepler, PA-C, and Kelly Johnston, PA-C and their assistants of Levy Dermatology, P.C. to provide health services to this minor in absence of a parent or legal guardian. These health services may include, but are not limited to examination, preventative and/or curative treatment, laboratory examination, anesthetic, medical or surgical diagnosis and any consultation deemed necessary at the physician’s discretion. Services shall not include research.

It is understood that this consent is given in advance of any specific diagnosis or treatment being required and is given to encourage and allow the physician and/or APP to exercise his/her best judgement as to the requirements of such diagnosis or medical treatment in my absence.

This consent shall remain in effect until revoked, in writing, by parent or legal guardian or until the child may legally consent for him or herself.

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