Dermatology Treatment Consent and Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Chart Number: _________________

Agreement Terms

1. Consent to Treatment

I hereby authorize Dr. _________________ and associates to perform dermatologic treatments and procedures as deemed necessary for my medical care. I understand that:

• The nature and purpose of the treatment(s) have been explained to me
• Alternative methods of treatment have been discussed
• Possible risks and complications have been disclosed
• No guarantees have been made regarding treatment outcomes

2. Financial Responsibility

I acknowledge that:

• Payment is due at the time of service
• I am responsible for any charges not covered by insurance
• A 48-hour notice is required for appointment cancellation to avoid fees

3. Photography Consent

I authorize clinical photographs to be taken for:

• Medical documentation
• Treatment planning
• Educational purposes (if specifically consented)

4. Medication Agreement

I agree to:

• Inform the practice of all current medications
• Report any adverse reactions promptly
• Not share prescribed medications with others
• Follow medication instructions as prescribed

5. Follow-up Care

I understand that:

• Regular follow-up visits may be necessary
• I must report any changes in my condition
• Emergency care may require referral to other facilities

Signatures

Patient Signature: _________________ Date: _________

Provider Signature: ________________ Date: _________

Witness Signature: _________________ Date: _________