Dermatologic Procedure Informed Consent Form

Patient Information

Name: _________________________
Date of Birth: __________________
Medical Record #: _______________

Procedure Information

Proposed Procedure(s): ________________________________________________
Treatment Area(s): ___________________________________________________

Consent Declaration

I, _________________________, hereby authorize Dr. _________________________ and/or such associates or assistants as may be selected by them to perform the following procedure(s).

Understanding of Procedure

• I understand that the procedure(s) will involve: [detailed description to be provided]
• The nature and purpose of the procedure have been explained to me
• Alternative methods of treatment have been discussed
• Expected outcomes and potential risks have been outlined

Acknowledgment of Risks

I understand that common risks may include:

1. Temporary redness and swelling
2. Bruising or discoloration
3. Post-procedure discomfort
4. Potential scarring
5. Infection risk
6. Changes in skin pigmentation

Specific Considerations

• No guarantee has been given regarding the final results
• I understand that additional treatments may be needed
• I have disclosed my complete medical history
• I agree to follow all post-procedure care instructions

Photography Consent

□ I consent to the photographing of the procedure site for medical documentation

Signatures

Patient Signature: ___________________ Date: __________ Time: __________

Witness Signature: __________________ Date: __________ Time: __________

Physician Signature: ________________ Date: __________ Time: __________

Emergency Contact

Name: _________________________
Relationship: ___________________
Phone: _________________________