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Minor Consent Form

If the client is a minor, they must be accompanied by a legal guardian who also provides a state-issued ID. If the last names or addresses of the minor and the guardian do not match, a birth certificate must be provided to prove legal guardianship (per Virginia DPOR regulations).

Only 1 guest is allowed in the procedure room.

The Minor Consent Form must be completed prior to arrival​

Minor's Date of Birth
Month
Day
Year

BIRTH CERTIFICATE IS ONLY NEEDED IF MINOR CHILD & PARENTAL GUARDIAN DO NOT HAVE THE SAME LAST NAME.

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