Consent to Treat a Minor

The following statement was read by the parent/guardian listed above:

I give written permission for Shenandoah Dermatology, P.C. and its representative physicians to make medical decisions/treat my child as listed above, since I, the parent/legal guardian listed above may not be present at all of his/her scheduled visits.

I understand that I or another parent/legal guardian must be present for my child’s first appointment. I give permission to the following listed adults to accompany my child and authorize treatment for my child’s subsequent visits in accordance with the office policy of Shenandoah Dermatology:

This includes bringing the child into the office of Shenandoah Dermatology, providing a history of present illness, disclosing protected health information, accompanying consented research study procedures, and witnessing any physical examination completed by the provider. This adult has the responsibility to relay any diagnosis, treatment plan or prescription(s) to the parent or legal guardian named above. I agree to be available by phone and to be financially responsible for all copays and coinsurance.

I also understand this signed consent will be valid until the minor child is 18 years of age, or unless I withdraw this permission in writing.

I certify that I understand and agree to the foregoing permission statement.