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Welcome to Bergen Dermatology Specialists

We look forward to seeing you for your visit.

Please fill out the electronic form below.
If you don’t want to fill out this form electronically, click here to print a PDF version and fill it out prior to your appointment.
Thank you.

Patient Information

First Name

M.I.

Last Name

Parent or Guardian Consent

Treatment to:
Accompanied MinorUnaccompanied Minor

Many times parents find themselves unable to accompany their children to appointments. This form has been prepared for your convenience should you at some time have some- one else accompany your minor children.

I give permission to Bergen Dermatology Specialists to the treatment of my son/daughter by any physician or physician assistant of Bergen Dermatology Specialists

I also agree that test results and/or medical information may be released to the above-named adult.

Many times parents or guardians find themselves unable to accompany their teen or young adult children to appointments. This form has been prepared for your convenience should you at some time be unable to accompany your minor.

I hereby grant Bergen Dermatology Specialists permission to treat my child when they arrive at the office unaccompanied.

Signature

Date

When you submit, your form will be sent to a HIPAA secure account.