Dermatology of Seattle

13610 First Avenue South, Seattle, WA 98168

206-248-5020 – 206-244-8425 (fax)

 

SURGICAL CONSENT

 

Name: _________________________                      Date: _____/_____/_____

 

          I am scheduled to have Excision of Cancer/Cyst/Mole or Other Growth to be performed by Dr. Levy and such assistants may be selected by him.

 

          I have been informed to my satisfaction of the mentioned procedure(s), why it is necessary, the risk to my health if the condition remains untreated and what the procedure will entail.

 

          I hereby give my permission for the administration of medication and pre-surgery instructions have been explained to me, as well as the procedure to be performed. Admission to a hospital of choice by the performing surgeon, if in his/her opinion such admission would be advisable.

 

          I also understand that during the course of the operation, unforeseen conditions may be revealed that necessitate an extension of the original procedure(s) or different procedure(s) than those planned. I authorize the above named surgeon or his designee(s) to perform such surgical procedures as are necessary.

 

          I have been made aware that there are certain risks inherent to the performing of any surgical procedure such as: loss of blood, infection, swelling, hematoma, pain, tingling, numbness or other nerve sensations including nerve damage, reactions to anesthesia and formation of thick or otherwise objectionable scars. Additionally, I acknowledge that the doctor has made no promises to me, oral or written, in connection with the operation. I recognize that every surgical procedure involves uncertainty and that no result can ever be guaranteed.

 

          Following surgery, I will/will not have a responsible adult drive me home as per previous arrangements. I realize that impairment of full mental alertness may persist for several hours following the administration of anesthesia, and I will avoid making decisions, taking part in activities which depend upon full concentration of judgment during that period.

 

          I release that doctor from any responsibility that takes place as a natural complication of the procedure. I also realize that impairment of full mental alertness may persist for several hours following the administration of sedatives or anesthesia.

 

          I, the undersigned, consent to the taking of photographs of me during the diagnostic and/or treatment sessions, operations and/or other surgical or medical procedures.

 

          I consent to the disposal of any tissue which is removed in accordance with accustomed practice and procedure. I give my permission to have any tissue removed during the procedure sent for histologic examination.

 

_________________________                                              _____/_____/_____

Patient/Guardian Signature:                                                    Date

 

_________________________                                              _____/_____/_____

Witness Signature                                                                   Date

 

_________________________                                              _____/_____/_____

Physician Signature                                                                 Date