AUTHORIZATION: I attest I am the Parent/Legal Guardian of the Person listed above under "1. Minor/Patient's Name" and authorize Alaska Family Dermatology, LLC & its personnel to deliver routine medical care to the person listed above as may be deemed necessary or advisable in the diagnosis and treatment of the listed Minor/Patient's Name. I allow the person(s) listed under section "3. Name of Person", & "6. Name of 2nd person, if applicable", to accompany this patient and act on my behalf. I am aware that I am responsible for payment of the patient portion at the time of service, regardless of my presence there. Routine medical care and interventions may include, but are not limited to: medical evaluation, physical exam, injections, liquid nitrogen treatment, skin biopsy, lab work (for monitoring when medications such as isotretinoin are prescribed). I have read, understand, and give my consent as stipulated above. My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand.