Universal Procedural Consent

I consent to the medical care and procedural treatment of the below that I have agreed to receive and that is considered necessary or recommended by my physician(s) and other healthcare providers. I understand that no guarantees have been made to me about the result of my indicated procedural treatment.*

Incision and DrainageSuture RemovalSuture PlacementOther

Possible Complications: Any medical procedure entails certain risks and complications. Although we expect good results, there can be no guarantee of outcome. Risks of certain procedures can include, but are not limited to any of the following:

SCAR/ALTERED APPEARANCE

Any medical procedure can result in scar formation. Wounds may heal with fine, line- like scars, wide scars, atrophic scars, or thickened keloid scars. Scars may be lighter or darker than surrounding skin or may be pink or red.

BLEEDING

Bleeding can occur after any medical procedure. This may take the form of oozing of blood from the wound site, sudden swelling of the wound, or excessive bruising around the wound or near it.

INFECTION

Infection can occur after any medical procedure. Excessive swelling, pain, redness or pus-like discharge from the wound can be a sign of infection. Contact us immediately if any of the afore mentioned symptoms occur.

PAIN, SWELLING, BRUISING

While these are normal consequences of some procedures, these symptoms can be minimized by following wound care instructions.

PROLONGED WOUND HEALING

Wound healing can be unpredictable, factors such as smoking, medications, and immunosuppression, and other medical conditions can prolong or impair wound healing.

WOUND DEHISCENCE

Sutured wounds can unexpectedly open and may lead to changes in healing options. Sometimes the wound can be resultured and other times the wound will have to heal

I have read and understand the consent form for the procedure being performed today. Also, I have read, discussed, understand and agree to the proposed procedure in detail with my healthcare provider and I consent to the procedure indicated above. The possible complications and any alternative treatment options available have been explained to me. I have been given the opportunity to ask questions and I have no remaining questions at this time.

Patient Name*

DOB*

Patient Signature*

Date*

Date