Permission to Accompany without Parent/Guardian

Permission to Accompany a Minor or Patient without the Presence of a Parent/Legal Guardian

Alaska Family Dermatology
By law, any child under the age of 18 years old cannot be seen by a doctor without written consent from a parent or without an adult present. If the minor is under 16, he/she must be accompanied by an adult. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.
1. Minor's/Patient's name*
2. Minor/Patient's Date of Birth*
For those occasions when you may not be with your child, please list those individual(s) age 18 or older who may give us consent for care:
3. Name of Person*
4. Phone Number of Person*
Please enter a valid phone number.
5. Relationship to Patient*
6. Name of 2nd Person, if applicable
7. Phone number of 2nd Person, if applicable
8. Relationship to Patient
Child's Health Information:
Current prescribed or over-the-counter medications and dosages:
Medication
Dosage
Medication
Dosage
Allergies illnesses or other comments
Health Insurance Information
No change since last visit (skip to next section)
Insurance Company
Policy Holder
ID Number
Group Number
Effective Date

MonthDayYear
Date
Copay
Authorization
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.
Limitations: Identify any specific limitations on the kinds of medical services for with this authorization is given. If none, check the box next to "None"*

NoneSpecific limitations listed below
Phone # for Parents/Legal Guardian completing form - you must be available by phone at time of visit*
This consent shall be in effect for:*

IndefinitelyDate(s) below (only)
Name of Parent/Legal Guardian of "1. Minor/Patient's Name" completing & signing form*

First NameLast Name
Relationship*
Parent or Legal Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Alaska Family Dermatology LLC 3340 Providence Drive Suite A358, Anchorage, AK 99508 Main: 907-268-2067 Main Toll-Free: 877-225-6494 Fax Toll Free: 855-395-0858 info@akfamilyderm.com
Should be Empty:

Permission to Accompany a Minor or Patient without the Presence of a Parent/Legal Guardian

Child's Health Information:

Health Insurance Information

Authorization