• Skin Surgery Consent Form

  • Birthdate
     - -
  • Format: (000) 000-0000.
  • Do you currently have any of the following problems in your skin?
  • Do you have a skin routine?
  • What products are you currently using on your skin?
  • Are you currently taking any medications?

  • Informed Consent

    I, hereby, consent to surgical procedure or treatment that is going to be applied. I understand the following possible risks involving: 

    • Pain
    • Bleeding
    • Infection
    • Scar formation (which can sometimes look worse than the original lesion)
    • Persistent redness
    • Increase or decrease of my skin pigmentation
    • Recurrence of the lesion
    • Local nerve damage or numbness
    • Severe allergic reaction to the local anesthesia, dressings, or medications

    I understand there may be other methods to apply the procedure. However, I agree to the procedure about to be applied, also understand all risks.

    I have been given the opportunity to ask all my questions regarding the procedure and risks.

    I agree that photographs or videos may be taken to use.

  • Current Date
     - -
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