Consent to Treat Minor Form Patient InformationPatient Name* First Last Age* D.O.B* MM slash DD slash YYYY Allergies* Parent or Guardian InformationPrint Name of Parent or Guardian* First Last Parent or Guardian Signature* Relationship to Patient* Emergency ContactName* Phone*Additional person to contact in the event the parent or guardian cannot be reached:Name* Phone*Consent to Treat a MinorIt 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.Authorization* I authorize and give consent to Skin Rehab for the evaluation and medical treatment of my minor child without the presence of a parent or legal guardian.
