Get Biopsy Consent Form

Soheil A. Hanjani MD FACOG FACS Obstetrics Gynecology 830 Oak Street Brockton MA 02301 508 583-4961 Fax 508 583-4732 CONSENT FORM FOR SKIN OR VULVA BIOPSY OR EXCISION Patient Name The risk and complications of the procedure include but are not limited to infection allergic reactions drug reactions bleeding pain and discomfort scaring of the skin with the possibility of poor cosmetic result possible need for re-excision. The nature of the procedure and the reason for performing it has been explained to me. The option of being referred to a dermatologist or plastic surgeon has also been discussed* I am aware that other unexpected risks or complications not discussed may occur and that no guarantees or promises were made concerning the results of any procedure or treatment. I am also aware that during the course of the proposed procedure unforeseen conditions may be revealed requiring the performance of additional procedures. I have read the above risk and complications of vulva/skin biopsy/excision* I have had the opportunity to ask any questions of my doctor and have received acceptable answers to my questions. I consent to the procedure. Patient Signature Date Physician Signature WOUND CARE INSTRUCTIONS 1. Keep wound dry for 24-48 hours. If it gets wet pad dry gently and change dressing* 2. Remove dressing 24-48 hours. If need to clean do so gently with mild soap and water. 3. If wound is not covered by steri-strips apply a small amount of Vaseline petroleum jelly and apply bandaid if possible use gauze and paper tape if sensitive to adhesives. 4. If stitches are present in the wound continue above regime daily until stitches are removed* 5. If no stitches are present in the wound continue above regime for 5 days and then keep wound covered or open to air as preferred* 6. If there are steri-strips leave in place for 5-7 days and then gently remove in the shower. 7. Keep your follow up appointment usually in 1-2 weeks. The option of being referred to a dermatologist or plastic surgeon has also been discussed* I am aware that other unexpected risks or complications not discussed may occur and that no guarantees or promises were made concerning the results of any procedure or treatment. I am also aware that during the course of the proposed procedure unforeseen conditions may be revealed requiring the performance of additional procedures. I am also aware that during the course of the proposed procedure unforeseen conditions may be revealed requiring the performance of additional procedures. I have read the above risk and complications of vulva/skin biopsy/excision* I have had the opportunity to ask any questions of my doctor and have received acceptable answers to my questions. I have read the above risk and complications of vulva/skin biopsy/excision* I have had the opportunity to ask any questions of my doctor and have received acceptable answers to my questions. I consent to the procedure. Patient Signature Date Physician Signature WOUND CARE INSTRUCTIONS 1. Keep wound dry for 24-48 hours.