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MOHS SURGERY
PRE-OP COUNSELING & CONSENT
Today's Date
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Patient Name
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First Name
Last Name
Date of Birth
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Email
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By initialing each statement, I confirm that I read and understand the information below:
If I prefer non-surgical options such as radiation or chemotherapy, I will not sign this form and do not need to continue filling it out. You have the option to schedule an appointment with your general dermatologist to review options or get a second opinion from another provider.
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If I prefer treatment alternatives or a second opinion, I will schedule an appointment with my general dermatologist or Dr. Uebelhoer.
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I understand the time I am given is my Check-in time, not my actual appointment time and that I may wait up a few hours before actually being seen. During this time, the surgeon and his team will be prepping for my case.
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I understand that Mohs surgery can take a long time (8 hours) as the purpose is to find the edge of the cancer very precisely. The size of the cancer is often much bigger than what is seen on the surface of the skin. For example, a tiny spot on the face (the size of an eraser head) may represent a deeper cancer that results in a large wound (the size of a quarter). I will keep this in mind, if I am hoping the surgery to be “quick” or “one layer.” In addition to the wait for layers, I understand that the surgery process can take a long time due to the time it takes to prepare for surgery, the procedure time and bandaging with post op instructions.
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I understand that my skin cancer is much larger than what I can see on my skin. If I would like to see typical wounds and repairs for my type and size of cancer I will ask for photographs or diagrams from San Diego Family Dermatology BEFORE I schedule my surgery date. Examples of surgical wounds have been shown to me.
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I understand that Dr. Uebelhoer will often coordinate care with other physicians (other dermatologists, plastic surgeons, or oncology specialists) as needed. This may mean a second provider will do the closure or other process.
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However, regarding the Mohs surgery itself, Dr. Uebelhoer does not “negotiate“ his decision to cancel or perform surgery, his technique, or fundamental preoperative, intraoperative, or postoperative principles and procedures. If I want the procedure done a specific way, (such as “the way my other doctor did it...”), or I cannot commit to following instructions specific for my case, or I simply cannot accept the potential wait times, surgical follow-up, suture removal schedules, etc. I will let San Diego Family Dermatology know BEFORE I schedule my surgery.
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SCHEDULING MY SURGERY DATE
I will not schedule any travel for at least 10 days following surgery. I will notify San Diego Family Dermatology if I have travel scheduled within 28 days of my surgery as sutures can be in for 1-6 weeks.
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I will prepare to be in the clinic for 8+ hours.
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I will only have one family member/caregiver with me on my surgery day. They are welcome to wait or leave and come back, however due to waiting room size restrictions we have to limit the number of people that come with you.
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I will arrange a driver as medications may be given during the procedure that may alter my ability to drive.
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My driver's name is:
First Name
Last Name
My driver's phone number is:
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Area Code
Phone Number
I will arrange to have someone watch over me for the first 24 hours as medications, bandages or pain may alter my ability to fully care for myself.
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My caregiver's name is:
First Name
Last Name
My caregiver's phone number is:
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Area Code
Phone Number
I will contact the office 3 business days prior to my surgery for any cancellations or rescheduling. Otherwise, I may be charged a $50.00 cancellation fee. After canceling or rescheduling 2+ times, we may need to schedule a consultation with Dr. Uebelhoer prior to rescheduling your procedure.
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I will prepare supplies that I will need at home before surgery: ● If the surgical site is on the lip, jaw or cheek, have soft foods available. ● If the surgical site is on the foot or lower leg we highly recommend purchasing compression socks (20-30 mmHg), a postoperative boot (please try it on before coming to the procedure) and a shower cover for your leg. (Examples on Amazon are: Aircast AirSelect Elite Walker Brace / Walking Boot and TKWC INC Waterproof Leg Cast Cover for Shower - #5738) ● Other supplies such as gauze, tape, non-stick pads, different size bandages, Aquaphor or Vaseline and gentle wound cleaner are needed for ALL SURGERIES.
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PLANNING FOR MY SURGERY DAY
I will plan for a good night’s sleep the night before surgery
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I will eat a full breakfast (which includes protein, carbohydrates and water prior to surgery)
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I will take all of my regular medications unless directed specifically by my doctor.
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I will bring an updated list of my medications to surgery.
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Do you usually take antibiotics prior to a procedure?
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No
Yes
I will not wear makeup, hairspray, fragrances or lotions.
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I will wear comfortable clothes, including a button-up shirt that is easy to take off without going over my face or the affected surgical site.
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I will bring reading material or something to help the time go by. Earphones are encouraged; however, they may not be compatible during certain times of my surgery. I am aware the office does have wifi to use during my wait time.
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I am to go straight home from surgery, with the possible exception of going to the pharmacy.
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I understand it is not necessary to cancel my appointment for cold like symptoms or even covid unless I feel too ill to come in.
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SURGERY DAY
Dr. Uebelhoer will determine if relaxing medications such as Valium or Ativan will be administered in the clinic prior to surgery. **There are several reasons for medications including but not limited to: reduction of pain and bleeding, decrease involuntary muscle contraction to improve safety, and to help me relax. If I plan to refuse these recommended medications I will let San Diego Family Dermatology know BEFORE scheduling my surgery date.**
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After the cancer has been removed, the wound may or may not be closed/stitched on the same day. Repairs may be days or weeks later. Reconstruction is highly variable and depends on many factors.
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Some wounds are better treated without stitches at all. This often means I will have more frequent in-office wound care. This is most common when the cancer is in a location where skin is under high tension, such as the legs, scalp and ear.
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Decisions about stitching the wound will occur after removal of the cancer. If I have a preference on how I want my wound repaired, I will let San Diego Family Dermatology know BEFORE scheduling my surgery date.
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AFTER SURGERY
I will be prepared to remain in bed for 72 hours after surgery. This is required for all sites.
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I will leave only to go to the bathroom or to the kitchen to prepare my meal.
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I will avoid swimming or sitting in a hot tub until my sutures are completely removed.
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I will avoid any activity or exercise that requires me to hold my breath until my sutures have been completely removed.
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I will avoid any strenuous activity or exercise that applies pressure or strain on the wound until my doctor authorizes.
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If I do more activity, I risk development of a wound infection and a poor scar result.
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San Diego Family Dermatology follows standard medical coding and billing procedures. When a repair is performed, certain follow-up visits are included for a specified period of time. When a repair is not performed and the wound is open, more frequent follow-up visits are typically needed. These are separately billed office visits.
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MY SIGNATURE BELOW INDICATES THE FOLLOWING:
I HAVE BEEN GIVEN ADEQUATE TIME TO HAVE ALL OF MY QUESTIONS
ANSWERED.
I HAVE READ AND AGREE TO ALL OF THE ABOVE.
MEDICAL HISTORY IS ACCURATE.
I AM AGREEING TO SURGERY.
PATIENT / GUARDIAN SIGNATURE
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