Minor consent

CHILDREN 16 and 17 YEARS OLD

Many times parents or legal guardians (P/LG)find themselves unable to accompany their teen or young adult children to appointments. This form has been prepared for your convenience.

The following conditions must be in place:

1. Your teen must be responsible and mature and understand this is a continuation of care which has already been performed while a P/LG was present.

2. Credit card in on file.

3. P/LG is readily available by phone during appoitnment time.

4. Consent is received for antipated procedure/evaluation. Only the consented concerns below will be addressed.

5. Each and every visit must have a consented form for the for the visit and should be a chronic condition such as acne, warts or extractions (teen facial).

6. All regular conditions of office still apply and general consent will be needed ("Patient forms" consent on website)

7. The person filling out this form is the parent or legal guardian

Any new rash or skin cancer or mole concern will need all parties present.

Note: All inital visits need a parent or legal guardian present.

Child's Name*

First Name (Name as printed on your insurance card)Last Name

Date of birth*

Parent's Email*

Phone Number for immediate reach of legal parent*

Area CodePhone Number

Legal parent or guardians's name

First NameLast Name

I consent to the following services for the above date's anticipated services: Check all that apply

Acne: medication review and refill. A telephone visit with P/LG will take place to review medication changes.Acne: extractions (by checking, I confirm that use of a sterile blade in order to lance deeper closed comedones is common in this procedure and understand the risk of: pain, bleeding, bruising, possible scarring, incomplete treatment response, or skin pigmentation).Acne- intralesional kenalog into large painful acne cysts (by checking I consent and understand the risk of skin depression, pain and bleeding, incomplete treatment response).Wart treatment (by checking, I consent to the use of a blade to pare down a large wart and/or the use of cryotherapy to freeze the wart. (by checking this box, I consent to this treatment an understand the risk of pain, bleeding, incomplete treatment response, need for multiple treatments, and possible skin discoloration).Other

Scheduled date of appointment

Date

Fee consent: I consent to charges incurred for the above services up to but not exceeding $250 as appropriate. I consent to a $50 no show fee for medical visits or a $125 no show fee for esthetican services if my teen fails to show or is 20 minutes beyond the appointment time and understand I will have to reschedule for the anticipated services.

My signature grants Lincoln Road Dermatology and its agents permission to treat my child as above, consent to charge my credit card on file as explained in the fee consent, and agree to the conditions set forth above.*

Name of person signing and filling out this form

First NameLast Name

Relation to patient/teen

Today's date

We reserve the right to verify accuracy of information and deny service. No show charges will apply.

Minor Consent