Medical Treatment Authorization and Consent

The following form is designed for those situations where minors are unaccompanied by either parents or legal guardians. This “Medical Treatment Authorization and Consent Form” gives authority to a designated adult to arrange for medical care for a minor in the event of an emergency. This is extremely important, in that, medical care cannot be provided to a minor without approval by the parents or legal guardians, unless there is written consent authorizing an agent to give approval.

Minor's Full Name

Address

Street Address Address Line 2 City State ZIP Code

Minor's Age

The undersigned do hereby authorize Visage Dermatology as he/she may designate as agent for the undersigned to consent to any anesthetic, medical, or surgical diagnosis or treatment for the above named minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and/or surgeon, licensed under the Provision of Medicine Practice Act whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, or elsewhere.

Parent or Guardian Signature*

Parent or Guardian Name

Address of Parent or Guardian

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Adult authorized to bring patient for appointments

Relationship to patient

Phone

This field is for validation purposes and should be left unchanged.

Central Avenue Office

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Appointment Request