Consent to Treat Minor Form

  • Patient Information

  • MM slash DD slash YYYY
  • Parent or Guardian Information

  • Emergency Contact

  • Additional person to contact in the event the parent or guardian cannot be reached:

  • Consent to Treat a Minor

  • It is the policy of Skin Rehab that all minors (under 19 years of age) seeking dermatologic treatment for the very first time or upon the onset of a new problem be accompanied by a parent or legal guardian.

    After the initial appointment, a minor may be seen by Skin Rehab for the same diagnosis without a parent or guardian present, upon completion of a Consent to Treat a Minor form. A new problem will require the presence of a parent or legal guardian. This form authorizes Skin Rehab to evaluate and treat your minor child with your consent.