Minor Consent Form

CONSENT FOR TREATING A MINOR
PLEASE NOTE: THE PARENT OR LEGAL GUARDIAN OF THE MINOR CHILD / PATIENT, MUST BE PRESENT AT THE FIRST APPOINTMENT.
- If the patient is a minor (0-17 years old), the parent or legal guardian must read, complete, and sign this form. This form is required to allow us to evaluate, treat, and bill for medical goods and services provided to a minor.
Minor child / Patient name:*

FirstLast
Minor child / Patient date of birth:*

MMDDYY
Parent / Legal guardian name:*

FirstLast
*
Email address
*
Phone number
I am an adult who is the:*

MotherFatherLegal guardian
I would like to be consulted prior to minor procedures such as mole removal, acne treatment, and wart treatment:*

YesNo
Signature:*

Clear
Should be Empty:

CONSENT FOR TREATING A MINOR