TFCZ01 Minor Consent Form

MINOR CONSENT FORM

To be completed by the parent/guardian of a patient 17 years old or younger.

I certify that I am the parent and/or legal guardian of the below named patient, and I consent to the examination and treatment of the patient by The Foot Clinic Staff, LLC/Dr. Ali Davis, DPM.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date

I authorize the person/s listed below to bring the patient to their appointments at the Foot Clinic, LLC.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Parent/Guardian Signature*

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: