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AUTHORIZATION TO TREAT A MINOR

I authorize 

,to examine, diagnose, and treat my child, 

,at his/her discretion in the event that I am

unable to accompany my child on subsequent office visits.

I am financilly responsible for the treatment of this patient and will remit payment to Mt. Pleasant Dermatology with the visit. 

Thanks for submitting!

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570 LONG POINT ROAD, SUITE 200

MT. PLEASANT, SC 29464

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(843) 968-2118

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