AFFZ11 Consent for Medical Treatment of a Minor Child

Consent for Medical Treatment of a Minor Child

***Parent or Legal Guardian MUST accompany minor on first visits***
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Appointment Date*

MonthDayYear
Date
I hereby give Affiliated Dermatologists consent for any medical treatment that may be required for my child during my absence at their appointment.
Parent or Legal Guardian’s Telephone Number*
Please enter a valid phone number.
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 or Legal Guardian’s Signature*

Clear
Name of Parent or Legal Guardian*

First NameLast Name
Should be Empty: