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.

(if left blank indefinitely or until minor is of legal age)

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