PATIENT CONSENT FOR PROCEDURE MINOR SURGERY/EXCISION OR SKIN BIOPSY

PATIENT CONSENT FOR PROCEDURE
MINOR SURGERY/EXCISION OR SKIN BIOPSY

Procedure:

I understand the nature of the procedure that has been recommended.

I have been informed of the benefits to be expected from this procedure as it compares to other available alternatives.

Possible Complications:

I hereby give my voluntary consent to the procedure described above.

I give my permission for a message to be left for me explaining the result of the biopsy or biopsies (initials),

Telephone Number:

Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

May 6, 2020 4:01 pm MST

PATIENT CONSENT FOR PROCEDURE MINOR SURGERY/EXCISION OR SKIN BIOPSY Uploaded by Dermatology Partners Inc - ilan@ntmatter.com IP 181.166.195.138