Cryotherapy Wart Removal Acknowledgement Form printable pdf download

Cryotherapy Wart Removal Acknowledgement Form

Cryotherapy Wart Removal

Cryotherapy wart removal is a procedure to treat your wart by freezing it. This is done using a cryogen

(freezing chemical), usually liquid nitrogen.

The procedure may result in the following adverse experiences or risks:



May be painful and cause blisters, scarring, or an open sore at the treatment area.



The part of your skin that was treated may darken or lighten.



The wart may not completely go away or may come back.



The wart may spread to other parts of your body.

After your procedure:

You may see a small ring of ice around your wart. Your caregiver may cover it with a bandage to keep it

clean and dry. When the procedure is over, you will be able to go home. You may have pain in the

treated area after the procedure. In a few weeks, the dead wart tissue may dry up and fall off.

I acknowledge the following points have been discussed with me:

 The potential risks of treating the wart

 The possibility that the procedure may NOT work for me

 That I am financially responsible for all charges in conjunction with this treatment or any future

treatments that may be necessary.

Acknowledgment

By my signature below, I acknowledge that I have read and fully understand the contents of this

informed consent form for treatment of warts. I have had all my questions answered to my

satisfaction by my healthcare team.

Patient Name (Please Print)

Patient’s Signature

Date

F PATIENT IS UNDER THE AGE OF

YEARS

OR IS OTHERWISE UNABLE TO SIGN

COMPLETE THE FOLLOWING

Patient is _____ year(s) of age or is unable to sign because:

____________________________________

Signature

Relationship to Patient

Date

Cryotherapy Wart Removal Acknowledgement Form