Patient: _________________________________________________

Date: ____________________

1. I hereby authorize Dr. _____________________________ to perform the procedure known as punch biopsy of the skin.

2. I understand that punch biopsy is a surgical procedure performed following the administration of local anesthesia. I understand that a small piece of skin or a portion of a skin growth will be removed for further examination under a microscope. While punch biopsy can completely remove a very small growth, generally this procedure does not completely remove larger lesions. I understand that punch biopsy usually produces a minimal scar. I understand that the practice of medicine is not an exact science, and that no guarantee can be made regarding the outcome of my planned procedure.

3. My doctor has explained to me that this procedure generally is safe, but that certain risks accompany any surgical procedure. Risks associated with punch biopsy of the skin include:

   Local bleeding and bruising in the surrounding tissues

   Pain associated with the surgery or the healing process

   Excessive scarring at the surgery site

   Allergic reaction to the numbing medicine or the surgical instruments

   Local infection in the surrounding tissues

   Damage to structures beneath the skin such as an artery or nerve

   Rare, unusual reactions, including possible death following any surgical procedure

4. I understand that there are alternatives to this procedure, including shave biopsy of the skin, lesion removal by fusiform excision technique or no excision at all. I understand that the other techniques may not provide the same advantages as the punch biopsy technique. I understand that I can refuse this procedure.

5. I understand that unforeseen conditions may alter the planned procedure. I give permission to my doctor to alter the procedure (such as to change the punch biopsy to fusiform excisional biopsy), if necessary, or to administer additional anesthetics or other medications if I should need them for the completion of my procedure.

6. I have read this form and the other information forms given to me by my doctor. I have had my questions answered to my satisfaction.

Witness: _______________________________  Patient: _______________________________

Date: _________________________________

Minor: _______________________________  Parent: _______________________________

Adapted with permission from Zuber TJ. Office Procedures. Baltimore: Lippincott Williams & Wilkins, 1999.