Minor Consent Without Legal Guardian

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Fields marked with an * are required

Many times parents find themselves unable to accompany their children to appointments. This form has been prepared for your convenience should you at some time have someone else accompany your minor children.

Name of Adult who will be accompanying Minor Patient *

Name of Minor Patient (son / daughter) *

I give permission to the accompanying adult listed above to consent to the treatment of my son / daughter (also listed above) by any provider at North Metro Dermatology. *

I also agree that test results and / or medication information released to the above-named adult. *

Name of Parent / Guardian *

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