PH 843.837.4400 | FAX 843.837.4440

BLUFFTON
7 ARLEY WAY, STE 101 | BLUFFTON, SC 29910
11 ARLEY WAY, STE 102 | BLUFTON, SC 29910
350 FORDING ISLAND RD, STE 100 | BLUFFTON, SC 29910

HILTON HEAD ISLAND
25 HOSPITAL CENTER COMMONS, STE 200 | HILTON HEAD, SC 29926

PORT ROYAL
1813 RICHMOND AVE | PORT ROYAL, SC 29935

Consent to Treat a Minor without a Parent or Legal Guardian Present

By law, any child under the age of 18 years old cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.

Minor Patient's Name

Date of Birth

For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child:

Check here if you wish to give consent for the minor to receive medical care without an accompanying adult. This consent may only apply to minors age 16 and older.

I (parent/legal guardian name) request and authorize May River Dermatology, LLC and its personnel to deliver routine medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor child. I am also aware that the adult presenting the child is responsible for payment of the patient portion at the time of service. I have the legal right to preauthorize May River Dermatology and its personnel to deliver routine medical treatment and services to my child. Routine medical care and interventions may include, but are not limited to: medical evaluation, physical exam, injections, lab work (examples: wart treatment with liquid nitrogen, minor suturing of lacerations).

I have read and fully understand this consent for treatment. By signing below, I consent to medical treatment. This consent will remain valid and enforceable until it is revoked (canceled) or replaced by a new form of consent.

Signature of Parent or Legal Guardian

Reset Signature

Date: