Procedure Informed Consent Form

This consent form is to help you decide and confirm your consent to proceed with a procedure. All treatment have benefits and risks.

The doctor undertaking the procedure for me is *

The procedure I am having is: *

My doctor has explained to me that this procedure generally is safe, but that certain risks accompany any surgical procedure. *

I understand risks may include but are not limited to: *

Local bleeding and bruising in the surrounding tissue
Pain associated with the surgery or the healing process
Unsatisfactory results including excessive scarring at the surgery site, unacceptable visible deformities, loss of function, wound disruption, delayed wound healing, skin death and loss of sensation
Allergic reaction to the numbing medicine, tapes or the surgical instruments
Infection following the procedure.
Damage to structures beneath the skin such as an artery or nerve
Rare, unusual reactions, including possible death following any surgical procedure
Additional surgery or other treatments may be necessary due to complications or recurrence.

I understand that there may be alternatives to this procedure. *

I understand that I can refuse this procedure. *

I understand that unforeseen conditions may alter the planned procedure. *

I consent to the taking and use of digital photographs of my skin during the health check. I understand that these photographs will be used as part of my medical record and may be shared with healthcare professionals as part of my care. *

I can request for a copy of this form. *

I have had my questions answered to my satisfaction. *

First Name *

Last Name *

Please enter your date of birth *

Email

Date

Signature

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