Surgical Consent Form printable pdf download

SHELBY DERMATOLOGY, PC

CONSENT FOR DERMATOLOGIC SURGERY

I have been told by Dr. Henderson/Dr. Bourgeois that I have been diagnosed as having the following

condition:

________________________________________ at _________________________________________

(condition)

(site)

Dr. Henderson or Bourgeois has recommended surgical removal as treatment.

•

I have been advised on possible risks and consequences associated with the recommended

•

procedure including, but not limited to bleeding, infection, scarring, alteration of skin color

and sensation, muscle weakness in the area or recurrence of the lesion or disease.

I understand that, in addition to doing nothing, there are alternatives to the recommended

•

procedure. I have been advised of the possible risks and consequences of these alternatives

as they compare to the recommended procedure.

It has also been explained that sometimes during a procedure it is discovered that an

•

additional procedure is needed immediately. I authorize the physician to proceed with such

additional procedures as are deemed necessary.

I acknowledge that no guarantees have been made concerning this procedure. I have been

•

advised that if I desire a further or more detailed explanation concerning my diagnosis,

recommended and alternative procedures, or possible risks and consequences, it will be given

to me by my physician. However, I am satisﬁed with the explanation given to me and I

authorize my physician and such assistants as may be selected by him/her to perform the

recommended procedure outlined above.

Do you have an immunosuppressive medical condition, or have you been advised by another

physician to take antibiotics during procedures to reduce the risk of infection for any reason such as

an artiﬁcial heart valve or joint.

___________________________________________________________________________________

_____________________________

_____________________________________

Witness/Date

Patient's signature (or person authorized

to consent for the patient.)

I have personally explained the above information to the patient or the patient's representative.

_____________________________________________

Physician Signature

Robert Henderson, MD / Gregory Bourgeois, MD

Surgical Consent Form