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
Feel free to call us at 585-266-5420 during regular hours, or write to us confidentially through our website’s secure contact page.
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