Patient: _________________________________________________

Date: ____________________

1. I hereby authorize Dr. _____________________________ to perform the procedure known as ingrown toenail removal.

2. I understand that this is a procedure performed under local anesthesia to treat a more severe case of ingrown toenails. The procedure will remove the lateral portion of the nail, creating a straight, new lateral nail edge. Electrosurgery is then used to destroy the cells that form the lateral nail so that a permanently narrowed nail results. This helps to prevent the problem from recurring. Heaped-up (hypertrophied) tissue that forms on the side of the toe is also removed. 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 ingrown toenail removal include the following:

   Bleeding, sometimes persisting for days after the procedure

   Pain associated with the surgery or the healing process

   Excessive scarring after the procedure

   Infection in the toe or the bones of the foot, or spreading into the body

   Allergic reaction to the numbing medication or surgical instruments

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

4. I understand that there are alternatives to this procedure, including antibiotic therapy, cotton-wick insertion below the nail, chemical destruction to the lateral toe, complete removal of the nail, and more extensive laser or surgical procedures. I understand that these alternate procedures may not provide the same benefits as the surgery proposed to me. 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 planned procedure (such as to suture injured tissue or biopsy unusual growths), 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 other information sheets 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.