Ganger DermatologyMinor Consent PARENT/GUARDIAN AUTHORIZATION: MEDICAL CARE FOR MINOR CHILDREN Adult IdentificationParent(s) or legal guardian(s) and legal custodian(s) of the minor child.Name(Required) First Last Name First Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)EmailWe will send a confirmation to this email once you submit the form Minor Child IdentificationChild Name(Required) First Last Child Date of Birth MM slash DD slash YYYY Special Medical ConcernsConsent(Required) I/We hereby authorize Ganger Dermatology to treat my minor child, as stated above, for office examination, medical treatment and/or dispensing of prescriptions while he/she is in your office. No surgical or medical procedures will be performed without completion of the appropriate consent form. The authorization will remain effective until minor turns 18 years old or written termination is provided to our office by parent or guardian.Signature(Required)Signature Δ
