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  • MOHS SURGERY

    PRE-OP COUNSELING & CONSENT
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  • By initialing each statement, I confirm that I read and understand the information below:

  • SCHEDULING MY SURGERY DATE

  •  -
  •  -
  • PLANNING FOR MY SURGERY DAY

  • SURGERY DAY

  • AFTER SURGERY

  • 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.
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