Skin Check Procedure Consent Form

"*" indicates required fields

I understand that skin check will involve a thorough skin check with a derma scope. Followed up by a discussion with

Doctor's Name*

Prefix First Last

This procedure is booked for a 30 minute time slot.

The doctor has discussed with the following:

The nature and purpose of the treatment
Additional methods of management that may be necessary if something unexpected happens
The complications that may occur
That the outcome of a method of medical management can never be absolutely guaranteed, even though it is carried out with due care

Patient Name*

First Last

Patient Address*

Street Address City State Postal Code

I have been informed of the following costs:

Should the appointment lead to a biopsy and/or an excision the GP will discuss any additional costs.

Patient Email*

A copy of this form will be sent to this email address.

Signature*

Date*

Providing comprehensive, family-centred healthcare for patients across Asquith, Hornsby, Mount Colah & Upper North Shore.