Minor consent over 16 yo

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 demonstrate responsibility and maturity, understanding that this visit is a continuation of care previously provided with a parent or legal guardian (P/LG) present. For any new concerns, you must remain available via video or phone for the duration of the medical visit.

2. Valid insurance, if applicable, and credit card is on file.

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

4. Consent is received for the anticipated procedure/evaluation.

5. Each visit must have a consented form and should be for 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, " yearly Financial and Office policy consents 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*

MonthDayYear

P/LG Email*

Phone Number for immediate reach of P/LG*

Please enter a valid phone number.

P/LG's name*

First NameLast Name

I consent to the following services for the anticipated appointment on the above date. Please indicate your consent by selecting the applicable letters or providing a detailed description of your concerns.*

A) Acne: medication review and refill. A telephone visit with P/LG will take place to review medication changes.B) 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). This can be accomplished with or without a chemical peel.C) 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).D) 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*

MonthDayYear

Would you like this consent to apply for the entire 2025 calendar year or just for the date listed above

Fee Consent: I consent to charges for the services provided, not exceeding $250, as applicable. I also agree to a $50 no-show fee for medical appointments and a $75 no-show fee for esthetician services. I understand that failure to provide at least 24 hours' notice to reschedule an appointment will result in a no-show fee for the time reserved. If my teen fails to attend the scheduled appointment or arrives more than 20 minutes late, I acknowledge that I will need to reschedule for the anticipated services. I also agree to maintain a valid credit card on file with the office to cover any charges, including those for no-shows or late cancellations.

By signing below, I grant Lincoln Road Dermatology and its agents permission to treat my child as described above. I also consent to charges to my credit card on file as outlined in the fee consent, and I agree to the conditions set forth in this document.*

Name of person signing and filling out this form*

First NameLast Name

Relation to patient/teen*

Today's date

MonthDayYear

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

Minor Consent