Consent Form

Please choose the applicable topic to give consent for.

Patient Name

First Name(s)Last Name(s)

Patient Date of Birth

Patient Sex (assigned at birth)

Are you trying to conceive, breastfeeding, or pregnant?

I consent to the below checked procedure(s). I understand that if my insurance does not cover this procedure that I will be responsible for the charge.

Skin biopsy. In this procedure, a small sample of skin is removed for analysis. Risks include (but are not limited to): scarring (flat, depressed, or elevated), permanent skin color changes/discoloration, infection, pain, bleeding, allergic reaction, incomplete removal, affecting nearby structures (like nerves or blood vessels), and recurrence of the skin lesion. Alternative treatment options include clinical monitoring.Skin excision. In this surgical procedure, a large piece of skin is removed for analysis. Risks include (but are not limited to): scarring (flat, depressed, or elevated), permanent skin color changes/discoloration, infection, pain, bleeding, affecting nearby structures (like nerves or blood vessels), allergic reaction, dehiscence (wound opening up), incomplete removal, recurrence of the skin lesion, and need for multiple treatments.Dermal fillers. In this procedure, dermal fillers are injected into the skin to add volume. Risks include (but are not limited to): allergic reaction, granulomatous reaction, under filling, over filling, asymmetrical results, affecting nearby structures (like blood vessels and nerves), skin necrosis, blindness, stroke, hearing loss, and need for multiple treatments. Filler material is usually absorbed by the body in 6-12 months. Complete satisfaction is not guaranteed.Hyaluronidase. In this procedure, hyaluronidase is injected into the skin to dissolve filler (hyaluronic acid). Risks include (but are not limited to) allergic reaction, infection, pain, bleeding, asymmetrical results, affecting nearby structures (like blood vessels and nerves), indented skin, removing too much or too little, and need for multiple treatments. Complete satisfaction is not guaranteed.Earlobe repair. In this procedure, a small part of the earlobe skin is removed and sutured together. Risks include (but are not limited to) scarring: (flat, depressed, or elevated), permanent skin color changes/discoloration, affecting nearby structures (like blood vessels and nerves), infection, pain, bleeding, unsatisfactory cosmetic results and possible need for correction. Complete satisfaction is not guaranteed.Other

Patient Assigned Sex at Birth

Are you (the patient) of reproductive potential/able to become pregnant without the use of contraceptives?

Please stop isotretinoin and let us know immediately if you develop any of the following symptoms. Isotretinoin (accutane) may cause side effects, some of which may be permanent, including but not limited to: increased pressure around the brain causing headaches and or vision changes, mood changes (including thoughts about harming yourself or others), bloody urine, inflammatory bowel disease (like Crohn’s or Ulcerative Colitis that usually presents as bloody stools or diarrhea), hair loss, elevated cholesterol, pancreas inflammation, liver injury, significant bone or muscle pain/injury, kidney injury (rhabdomyolysis), and dryness (including lips, mouth, and nose).

Please do not donate blood, drink alcohol, or take the medications called doxycycline, minocycline, or tetracycline while on isotretinoin.

In general, we recommend avoiding elective procedures, surgeries or skin procedures (such as laser hair removal, other skin laser treatments, chemical peels, electrolysis, etc) while on or within 6 months of being on accutane. If you are having any planned surgeries or procedures while on or within 6 months of finishing isotretinoin, please let your surgeon know that you are (or were in the past 6 months) on isotretinoin. Please also let Dr. Khalil know. Isotretinoin may affect healing after surgery / procedures.

Blood checks are required every month while on isotretinoin. Please get your blood checked when you are on your 25th pill and schedule a follow-up appointment (either virtual or in-person) for 2-3 days later. You can have water or plain tea without sugar before the blood draw.

Patients cannot be pregnant 1 month before starting isotretinoin, while taking isotretinoin, and 1 month after discontinuing isotretinoin. You need 2 normal blood checks and negative pregnancy tests separated by one month before starting isotretinoin, then bloodwork and a negative pregnancy test every month you are on isotretinoin. The window for your blood check, visit, and medication pick-up ends within 6 days. For example, if you have your blood drawn on a Monday, you must have a follow-up appointment on Wednesday and pick up your medication by 11:59PM Sunday night. If you fail to do this, you will be required to take another pregnancy test at a CLIA certified lab like Quest (we do not do pregnancy tests in our office). To avoid this, we highly recommend picking up your isotretinoin on the same day as your follow-up visit.

If your insurance requires Prior Authorization to determine coverage for isotretinoin, it is your responsibility to initiate this process with the pharmacy and inform us of the need for Prior Authorization. Often, pharmacies and insurance companies fail to inform the provider's office that Prior Authorization is required. If your insurance requires Prior Authorization, there may be a delay in receiving your medication and you may be required by the iPledge program to be put in a holding period before being able to submit another negative pregnancy test.

You must log into the iPledge system and answer comprehension questions every month after we register you in iPledge. Your iPledge ID number can be found on your iPledge program consent form. We highly recommend writing down (or taking a picture with a cell phone) your iPledge ID number to have it available when you go to the pharmacy to pick up your medication.

The iPledge username and password is mailed and or emailed to you by the iPledge program. If you did not receive it within 2 weeks of your initial registration into the program, you must call the iPledge program at 1-(866) 495 - 0654 to retrieve your login information. You must have an active username and password before you can begin the program.

I understand that I must have my blood drawn when I have taken my 25th pill of each month, and that I must schedule a follow-up appointment (either virtual or in-person) to discuss and review my lab results within 2-3 days of my blood draw.

I understand that iPledge allows a 6-day window to pick up my medication, and that I am encouraged to pick up my isotretinoin prescription the same day as my follow-up appointment to prevent missing this window.

I understand that I must log into the iPledge system and answer comprehension questions every month after I am registered in the iPledge program. If I fail to answer my comprehension questions, I will not be eligible to pick up my isotretinoin prescription.

I understand that if I did not receive my iPledge username and password within 2 weeks of my initial registration into the program, it is my responsibility to call the iPledge program at 1 (866) 495-0654 to retrieve my login information.

I agree to inform all of my doctors/other providers and my pharmacist that I am taking isotretinoin.

I understand that I am not to take any dietary supplements, to drink significant quantities of alcohol, or to exercise extensively (such as running a marathon) while on isotretinoin.

I understand that if I develop muscle pain, bloody or discolored urine or stool, vision changes, headaches, mood changes, thoughts about harming myself or others, or any other concerning symptom, I will stop taking isotretinoin immediately, call Dr. Khalil's office (press 9 if after-hours), and go to an urgicare or hospital emergency room.

Unfortunately, if you are trying to conceive, pregnant, and or breastfeeding, you CANNOT receive BOTOX®, filler injections, or a chemical peel. Please stop filling out this consent form and let the medical assistant (MA) know.

Are you allergic to the numbing medication lidocaine + epinephrine?

Please specify the details of your numbing medication allergy.

Do you have any family or personal history of any neuromuscular disorder? (eg. Myasthenia gravis, Lambert-Eaton Syndrome, Amyotrophic Lateral Sclerosis)

Please specify any history of neuromuscular disorder.

Have you had any allergic reactions or significant issues with prior filler procedures?

Please specify any prior allergic reactions or significant issues with filler.

Please have the medical assistant (MA) sign below acknowledging understanding of your responses to our consent form.

I give consent to DK Dermatology PLLC and its personnel to administer medical care to my child in the event that I am unavailable to physically accompany my child in the office. This includes but is not limited to medical evaluations, physical exams, discussing and prescribing over the counter and prescription medications including prescription pills and creams. This consent is active until further notice is provided in writing.

I, in addition, give permission for the below:

Other

Reason for medical records release request:

I authorize DK Dermatology PLLC to release/receive my medical records/information to/from the following entities:

Provider/Facility Name and Address

Provider/Facility Name

Street Address

CityState / Province

Personal Contact's Name

First Name(s)Last Name(s)

Relationship to Patient

Please choose the option that best matches your relationship to the person listed above.

Personal Contact's Phone Number

Format: (000) 000-0000.

Personal Contact's Email

Information to Be Disclosed

Other

Specific Records to Be Disclosed

Please specify the record type and date of service (if known).

I give permission to send these records over unencrypted email. I realize email is not a secure connection.

Patient's Email

Prior to my visit with a specialist doctor, my insurance policy requires that I have a referral on file from:

Other

I understand that failure to submit a referral prior to my visit may result in my insurance company denying my visit claim.

If my insurance policy requires that a specific form or other documentation needs to be attached with my referral, I acknowledge that it is my responsibility and not the responsibility of the office to provide this completed form or other documentation before my visit.

I am being asked to complete this form because I have not provided a referral before my appointment with Dr. Khalil, a specialist doctor (dermatologist). There is no guarantee that a referral received after the date of my visit or a referral from a doctor that is not my designated/assigned Primary Care Physician (PCP) listed on file with my insurance company will be accepted. Most often these referrals are rejected. If I cannot produce a referral valid for the date of my visit that my insurance accepts, I acknowledge that the balance from my visit claim will defer unto me in full. It is my sole responsibility to pay off this balance in a timely manner, or I will face collections charges which may possibly impact my credit score/report.

I am aware that I have the right to inspect and receive a copy of the health information I have authorized to be used and/or disclosed by the Authorization. In addition, I understand that I do not need to sign this Authorization in order to receive treatment. I also am aware that I may revoke this Authorization by notifying the disclosing medical records/health information department in writing. However, I understand that my revocation will not be effective as to uses and/or disclosures: (1) already made in reliance upon this Authorization; or (2) needed for an insurer to contest a claim/policy as authorized by law if signing the Authorization was a condition to obtaining insurance coverage. I realize that the information used and/or disclosed pursuant to this Authorization may be subject to re-disclosure and no longer protected by federal privacy law.

Patient/Guardian Signature

Parent/Guardian Name (if other than the patient)

First Name(s)Last Name(s)

Today's Date

***Note: After clicking "Submit", please do not close your web browser until after the page has refreshed and you are redirected to the "Thank You" page.