APDerm Consent Form for Treatment of a Minor

Consent Form for Treatment of a Minor

It is the policy of the Practice that all minors seeking treatment be accompanied by a parent/legal guardian for the first visit. After the initial appointment, a minor may be seen at the office for treatment without the parent/legal guardian present if this consent form is filled out and maintained in the patient’s medical record.

Treatment of a minor requires a team effort by the medical care provider(s) and the patient’s parent or legal guardian. The parent or legal guardian’s responsibility includes supporting the medical directives given by the medical provider. The medical provider’s role includes ensuring that the parent or guardian is aware of and concurs with the treatment and charges their child receives. I acknowledge and understand that:

• I allow the Practice to evaluate and treat my child including general dermatology care, minor surgical procedures, injections, immunizations, and the writing of all prescriptions when my child’s parent/legal guardian is not present. 
• My consent must be renewed annually until my child is 18 years old by completing this form each year.
• I can change my consent at any time by contacting the dermatology office where my child receives his/her care, but that my cancellation will not have an effect on actions taken prior to my cancellation.
• My consent is voluntary, and I may cancel this consent without affecting my child’s rights to receive health care at the Practice.

By signing below, I acknowledge that I am the parent/legal guardian of the patient with authority to consent to treatment, that I have read and understand this consent document for the stated procedure, and that all my questions have been answered in a language that I understand.