Authorization To Treat A Minor


Authorization to Treat a Minor
Aesthetic & Clinical Dermatology Associates suggests that parents or guardians with
minor children complete this Consent to Treat Minor Form. This gives legal permission
to treat your child if you cannot accompany your child.
The law requires that we receive permission from a parent or guardian before treatment if
it is not life threatening.
This authorization will remain in effect until revoked in writing by parent/guardian.
This authorization shall remain a permanent part of my child’s Aesthetic & Clinical
Dermatology Associates Medical Record.
I, ________________________________________________________________
Parent(s) or Legal Guardian- please print
give permission to: Aesthetic & Clinical Dermatology Associates to provide
dermatological care for my child ____________________________________.
It is without pressure or coercion that I sign this consent.
Signature: _______________________________________
Date: _____________
Parent/Legal Guardian
Signature: _______________________________________
Date: _____________
Parent/Legal Guardian
Witness: ________________________________________
Date: _____________
Medical Staff
Ver. 11/17/2008


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