Permission to Treat a Minor

I give permission to my child to attend his/her illness appointment alone without my presence and authorize treatment for my child in accordance with the office policy of Advanced Dermatology Laser & Cosmetic Surgery. This includes providing a history of present illness, disclosure of protected health information, and responsibility for relaying any diagnosis, treatment plan, or prescription(s) to the parent or legal guardian mentioned above. I agree to be available by phone and to be financially responsible for all co pays and coinsurance.

This authorization is effective on:
and expires

Emergency Contact Information for Parents/Guardians:

Where/how can you be contacted in case of emergency?

Phone:

E-mail address:

Parent of Legal Guardian’s Signature: ______________________ Date:

*Please print and bring the permission form with you for your appointment. Please be aware that themedical staff will not be able to provide care without proper documentation.

*Пожалуйста, распечатайте и возьмите с собой бланк разрешения на визит. Пожалуйста,имейте в виду, что медицинский персонал не сможет обеспечить уход без надлежащей

Thank you.