CONSENT TO TREAT MINOR PATIENT WITHOUT PARENT PRESENT In order for us to treat a minor without a par 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field where it states 'I, _________(print name here)'. This identifies you as the parent or legal guardian.
3. Next, fill in the minor's name in the space provided: '_______(print name of minor)'. This ensures that the consent is specific to your child.
4. Input the date of birth of the minor in the format '__/__/__'. Accurate information is crucial for medical records.
5. Review the authorization statement carefully. It outlines what medical care you are permitting Northern Virginia Dermatology to provide.
6. Sign and date the form at the bottom. Your signature confirms that you understand and agree to the terms outlined.
7. Lastly, provide your contact numbers (home, cell, work) to ensure that you can be reached if necessary.

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