Healthcare Dermatologists Consent Form

HEALTHCARE DERMATOLOGIST CONSENT FORM

Patient Information

Patient Name:

Male Female Other Decline to state

Insurance Information

Medical History

Bleeding disorder or blood thinner therapy: Yes No

Pregnant or breastfeeding: Yes No

Planned Procedure(s) and Anesthesia

I authorize the dermatologist and clinical staff to perform the following procedure(s):

Shave biopsy Punch biopsy Excision / removal of lesion Cryotherapy (liquid nitrogen) Laser treatment Chemical peel Injection (steroid, filler) Other:

None Topical anesthesia Local injection Other / sedation:

Risks, Benefits, and Alternatives

I understand that all procedures involve some degree of risk. Risks specific to dermatologic procedures may include infection, bleeding, scarring, pigmentary changes, incomplete removal or recurrence of the lesion, nerve injury, allergic reaction to medications or topical agents, prolonged wound healing, and need for additional procedures. Rare but serious complications may occur. The expected benefits include diagnosis, removal of suspicious or symptomatic lesions, symptom relief, and cosmetic improvement.

Alternatives to the proposed procedure(s) include no treatment, observation, medical therapy, different procedural approaches, or referral for further evaluation. I have had the opportunity to discuss alternatives and to ask questions.

By initialing below I confirm that these risks, benefits, and alternatives were explained to me and I understand them:

Initials:

Specimens, Pathology and Photographs

I authorize submission of any tissue removed during the procedure for pathological examination and understand that pathology results will be communicated to me. I authorize clinical photography for medical records, diagnosis, treatment planning, teaching, and quality assurance. Photographs used for teaching or publication will be de-identified unless I provide separate written authorization.

I consent to photography: Yes No

Consent for Treatment and Release

I authorize the dermatologist and clinical staff to perform the described procedure(s) and to administer such local anesthesia, topical agents, or adjunctive measures as deemed necessary. I understand that the practice will take reasonable measures to provide safe care. I acknowledge that no guarantee or assurance has been made to me about the results that may be obtained.

I hereby release the dermatologist and the associated clinical facility from liability for complications or adverse outcomes resulting from the procedure except in cases of gross negligence or willful misconduct. I agree to follow post-procedure instructions and to seek follow-up care as recommended.

Patient Rights and Withdrawal

I understand that I may withdraw consent at any time prior to the procedure without affecting my right to future care. Withdrawal after administration of anesthesia or once the procedure has commenced may not be possible. I have had the opportunity to ask questions and they have been answered to my satisfaction.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the practice’s notice of privacy practices and understand that my protected health information may be used and disclosed for treatment, payment, and health care operations. I authorize the release of information necessary to process insurance claims and for continuity of care.

I authorize disclosure of my health information to the following persons (name and relationship):

Acknowledgment and Signature

By signing below I confirm that I have read and understand this consent form, that all my questions have been answered, and that I consent to the procedure(s) and related care described above. If signing on behalf of the patient, I certify that I am authorized to consent for the patient and that my relationship to the patient is indicated below.

Sign Now