Minor Child Medical Authorization Form

It is the policy of Helendale Dermatology & Medical Spa to have a parent or legal guardian present during a minor patient’s initial visit.  This helps the parent/guardian have a comprehensive understanding of your child’s care and treatment options.

In the event a parent or guardian cannot be present during a future visit(s) please read and sign the below agreement.

I, the undersigned parent/legal guardian, of the minor above do authorize the providers at Helendale Dermatology & Medical Spa to provide healthcare services to this minor in the absence of a parent/guardian.  I understand that the healthcare services/spa services may include, but are not limited to examination, medical or surgical diagnosis, local anesthetic, and preventative and or curative treatment.

Telephone Number(s) where Parent/Guardian can be reached at the time of the minor’s appointment.

Specialist in healthy, beautiful skin.

500 Helendale Road         Suite 100         Rochester, NY 14609       585.266.5420      fax 585.266.5423