Patient: _________________________________________________

Date: ____________________

1. I hereby authorize Dr. _____________________________ to perform the procedure known as minimal excision of an epidermoid (sebaceous) cyst.

2. I understand that this is a procedure performed under local anesthesia. I understand that my doctor may attempt removal of the cyst through a small incision. If the cyst is scarred, it may require the standard removal technique through a larger incision. I understand that my doctor will attempt to remove the entire wall of the cyst so that it does not recur. 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 is generally safe, but that certain risks accompany any surgical procedure. Risks associated with epidermoid cyst removal include:

   Bleeding and bruising in the surrounding tissue

   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 the structures below the skin, such as nerves or blood vessels

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

4. I understand that there are alternatives to this procedure, including simple incision and drainage, placement of iodine crystals into the cyst, electrosurgical or laser destruction, or freezing (cryosurgery) of the cyst. I understand that I can refuse the surgical removal procedure.

5. I understand that unforeseen conditions may alter the planned procedure. I give permission to my doctor to alter the procedure (such as switching to the standard removal technique using a larger incision), 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.