Mole/Skin Tag Removal Form

MOLE/SKIN TAG REMOVAL CONSULTATION

AND CONSENT FORM

Please answer the consultation questions appropriately. This questionnaire will guide us for your upcoming treatment.

Full Name *

Phone *

Email *

Date of birth *

Medical History

Do you have any allergies? If yes, please specify: *

Are you currently taking any medication? *

Yes

Do you have any history of skin diseases, disorders, or issues? If yes, please specify: *

Are you currently pregnant or nursing? *

Yes

Do you have a history of keloid scarring? *

Yes

Consent and Acknowledgment

Please ensure that you have had all of your questions answered by the cosmetic nurse and/or dermal therapist before signing.

Cosmetic Mole Removal / Lesion Removal If the mole(s) is determined to be benign by a specialist, the cosmetic nurse can expertly remove your lesion under local anesthetic in the clinic under sterile conditions. A dressing may be applied. You will be given instructions on how to care for the site. You may be required to visit the clinic for a follow-up appointment to check the healing process.Ideal candidates for lesion removal are going to be those with smaller moles, lipomas, fibromas, skin tags, warts, age spots, and/or sunspots.

Risks and Complication Please note:

No medical provider can guarantee a "scarless" procedure. The procedure will be performed in a way meant to minimize the visibility of scarring. The scar will initially be red and raised but usually reduces in colour and size over several months. The healing process can take between 2 to 4 weeks. Some people have an abnormal response to skin healing and these people may get larger scars than usual (keloid or hypertrophic scarring). If the area becomes reddened, very painful or drainage is present, please call the clinic. Failure to comply with post-care instructions may result in undesired and unpredictable results.

Photographs

I authorize the taking of clinical photographs and their use for clinical purposes by the physician and the team. I understand my identity/confidentiality will be protected.

Disclosure of Health Information

- I have provided full disclosure of my health history and medication on the form completed at intake.

-I have had all skin tags/ moles checked by my GP prior to todays removal

- I have read and understand ALL of the information provided above, and am aware of the potential risks/ benefits of having/not having this treatment.

- I have had sufficient opportunity to discuss my concerns/ questions with the cosmetic nurse. This consent is considered valid for subsequent treatments unless revoked in writing.

- I consent to receiving cosmetic mole removal/lesion removal treatment by the cosmetic nurse.

I CONFIRM

I am 18 years or over.-
I understand that there is no refund for any of the services performed.I am fully aware that this procedure is made voluntarily, and I have had the opportunity to ask questions and have them answered to my satisfaction.
I have been informed about the aftercare instructions and commit to following them diligently.
I release the practitioner and the establishment from liability if any complications or unfavourable results arise from the treatment.
I understand the costs associated with this procedure and accept full responsibility for these costs.
I certify that I have voluntarily sought the services provided and consent to the treatment.

Signature *

Clear

By signing and ticking this, I have read and agree to the clinic procedures of the treatment(s) that I have availed and abide from the instructions.