Consent For Medical Treatment Of A Minor Form

Consent for Medical Treatment of a Minor

Effective January 1

2018

Patient Name:

Patients Date of Birth:

All minors seeking medical treatment must be accompanied by a parent/ legal guardian during the first office visit for a new

treatment. After the initial appointment, a minor may be seen for treatment only with written authorization from the

parent/guardian under the conditions specified in this consent. If the parent/legal guardian cannot attend the appointment, the

following instructions that you select will be adhered to in the treatment of the minor patient:

REFILLS:

Yes/ No

I authorize Radiant Dermatology to re-fill prescriptions for the minor as deemed necessary for treatment.

NEW DIAGNOSIS:

Yes/ No

I authorize Radiant Dermatology to treat a new diagnosis under the condition that Radiant Dermatology obtains

verbal consent from the parent/legal guardian before the new diagnosis is treated. If a new diagnosis is

rendered during a return visit during which the parent/legal guardian is not present, Radiant Dermatology may

treat the new diagnosis with verbal consent from the parent/legal guardian. If the parent/legal guardian cannot be

reached at the time of the visit, the new diagnosis will not be treated and a follow-up appointment will be

scheduled.

NEW PRESCRIPTIONS:

Yes/ No

I authorize Radiant Dermatology to write a new prescription for the minor as deemed necessary for treatment.

Some medications require that bloodwork and/or a pregnancy test (such as Accutane for the treatment of acne) be

given before prescribing/refilling. In these circumstances, the parent/legal guardian/appointed adult must be

present.

OFFICE PROCEDURES:

Yes/ No

In the absence of a parent/guardian/appointed adult, I authorize the minor patient to sign any required consent

forms for treatment of lesions requiring minor procedures such as biopsies, liquid nitrogen or injections. Any

procedure performed by Radiant Dermatology requires that a separate consent form specific to that procedure be

signed by the patient/legal guardian/appointed adult prior to every treatment.

If you need to send your child to their appointment with an adult other than yourself/legal guardian, please complete this

section:

I appoint the following adult

, whose relationship to the child is

, to consent

to medical care which is deemed necessary by Radiant Dermatology as authorized herein. A parent/legal guardian may appoint

another to accompany the minor patient to the appointment.

, am the parent/legal guardian of the minor child

. I have the legal right to

consent for medical treatment for this patient. I hereby authorize Radiant Dermatology to provide medical treatment as indicated

above. I understand that this consent will be voided for 12 months from the date signed unless revoked by me in writing.

Parent/Legal Guardian Name

Parent/Legal Guardian Signature

Date

Consent For Medical Treatment Of A Minor Form - 2018

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