Unaccompanied Minor Consent

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Fields marked with an * are required

Many times parents or guardians find themselves unable to accompany their teen or young adult children to appointments. This form has been prepared for your convenience should you at some time be unable to accompany your minor.

Name of Minor Patient (son / daughter) *

I hereby grant North Metro Dermatology permission to treat my child (listed above) when they arrive at the office unaccompanied. *

Name of Parent / Guardian *

Phone Number *

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