Consent Form for Skin Tag Removal via Electrocautery

Let us do this part

Today's Date:

Sun May 18 2025 03:47

Please read and answer

**1. Purpose of Procedure:***

I acknowledge that: The purpose of this procedure is to remove one or more skin tags using electrocautery, a technique that uses an electrically heated instrument to burn and remove the skin tags.

**2. Description of Procedure:***

I acknowledge that: The skin tag removal via electrocautery will involve the following steps:
- Cleansing the area around the skin tag.
- Applying a local anesthetic to minimize discomfort.
- Using an electrocautery device to burn and remove the skin tag.
- Applying an antiseptic and dressing to the treated area

**3. Risks and Complications:***

I understand that while skin tag removal via electrocautery is generally safe, there are potential risks and complications, including but not limited to:
- Infection
- Bleeding
- Scarring
- Discoloration of the skin
- Pain or discomfort at the site of removal
- Allergic reaction to anesthesia or materials used during the procedure
- Recurrence of skin tags

**4. Aftercare Instructions:***

I understand that following the procedure, I will be given specific aftercare instructions which may include:
- Keeping the area clean and dry
- Applying prescribed or recommended ointments
- Avoiding certain activities that may irritate the area
- Monitoring the site for signs of infection or other complications

**5. Alternatives to Procedure:***

I understand that there are alternative methods to manage or remove skin tags, including:
- Doing nothing (leaving the skin tags as they are)
- Over-the-counter treatments
- Cryotherapy (freezing)
- Excision (cutting)
- Seeking a second opinion or consultation with another healthcare provider

**6. Acknowledgment of Understanding:***

I acknowledge that:
- I have had the opportunity to ask questions about the procedure, its risks, and benefits.
- All my questions have been answered to my satisfaction.
- I understand that no guarantees or promises can be made regarding the results of the procedure.

**7. Consent to Procedure:***

By signing this form, I voluntarily consent to the skin tag removal procedure via electrocautery performed by the practitioner listed above. I understand that I can withdraw my consent at any time prior to the procedure.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:*

Address:

Postcode:

Date of birth:*

Phone #:*

Email:*

Signature:*

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Emergency Contact

If something happens, your emergency contact might need to explain your medical history, allergies, or medications.

Name:

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