Cosmetic Skin Tag Removal Consent Form

You have the right and obligation to make decisions concerning your health care. Your doctor can provide you with the necessary information and advice, but because this affects you, you must enter into the decision making process. This form has been designed to acknowledge your acceptance of treatment by your doctor. Please feel free to ask any questions.

1. I hereby authorize NANCY CHEN, M.D. (and any associate or assistant involved in my care) to treat the following condition(s) which has (have) been explained to me.

PROFESSIONAL: Skin tags on/around:*

Specify area

ORDINARY OR LAY LANGUAGE: Skin tags on/around:*

Specify area

2. The procedure(s) planned for treatment of my condition(s) has (have) been explained to me by my doctor as follows:

PROFESSIONAL: Skin tags on/around:*

Specify area

ORDINARY OR LAY LANGUAGE: Skin tags on/around:*

Specify area

3. I recognize that, during the course of the operation, post-operative care, medical treatment, anesthesia, or other procedure, unforeseen conditions may necessitate my above named doctor, and her assistants, to perform such surgical or other procedures as are necessary to preserve my life or bodily function.

4. I have been informed that there are many significant risks, such as sever loss of blood, cardiac arrest, and other consequences that can lead to death or permanent or partial disability, which can result from any procedure.

5. No promise or guarantee has been made to me as a result or cure.

6. I consent to the administration of (general, regional, local) anesthesia by an anesthesiologist, by my attending physician, or by other qualified individual under the direction of a physician as may be deemed necessary. I understand that all anesthetics involve risks that may result in complications and possible serious damage to such vital organs as the brain, heart, lungs, liver and kidney. These complications may result in paralysis, cardiac arrest and related consequences or death from both known and unknown causes.

7. Any tissues or parts surgically removed may be disposed of by the center or doctor in accordance with accustomed practice.

8. I consent to the photographing, videotaping, televising, or other audio and/or visual recording of this operation, post-operative care, medical treatment, anesthesia, or other procedures for medical or scientific purposes or for the purpose of advancing medical education, provided my identity is not revealed by the pictures, by the recording or by the descriptive texts accompanying them.

9. Also, for the purpose of advancing medical education, I consent to the admittance of observers to the operating room, during my post-operative care, medical treatment anesthesia or other procedures.

10. Additional Comments:

11. I have had the opportunity to ask questions about this form.

FULL DISCLOSURE

I AGREE THAT MY PHYSICIAN HAS INFORMED ME OF THE:

Diagnosis or probable diagnosis
Nature of the treatment or procedures recommended
Risks or complications involved in such treatment or procedures
Alternative forms of treatment, including non-treatment, available
Anticipated results of the treatment

Signature of Patient or Legal Representative*

Patient's Name*

First NameLast Name

Patient's Date of Birth*

Patient ID#*

Date*

If patient is a minor, unable to sign or without decision making capacity, relationship of person authorized to consent must be stated.

Name of Legal Representative

First NameLast Name

Relationship to Patient

Witness Signature*

Witness Name*

First NameLast Name

Physician's Signature*

Physician's Name*