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Informed Consent Form

Fusiform Excision

Patient: _________________________________________

Date: _________________________________

1. I hereby authorize Dr. ______________ to perform the procedure known as the fusiform excision biopsy.

2. I understand that this is a procedure performed under local anesthesia to remove a growth or tumor from the skin or the tissues beneath the skin. I understand that this procedure is designed to remove the abnormal tissue for examination under a microscope. It is possible that the growth will not be completely removed and that another procedure will be required. 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 the fusiform excision procedure include the following:

   • Persistent or excessive bleeding that may require hospitalization or transfusion
   • Damage to a nerve or artery beneath the surgical site, producing temporary or permanent numbness or muscle weakness
   • Skin death in the skin of the sides of the surgical wound
   • Excessive or unsightly scar formation that may require correction at a later date
   • Allergic reaction to the numbing medication or surgical instruments
   • Damage to nearby structures, such as the eye or nose, when operating on the face
   • Infection in the local tissues or spreading to other areas
   • Rare, unusual reactions, including possible death following any surgical procedure

4. I understand that there are alternatives to this procedure, including shave excision or a partial biopsy technique such as punch biopsy. I understand that I can choose not to biopsy this growth, and 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 suture bleeding vessels at the base of the wound), if necessary, or to administer additional anesthetics or other medications if I should need them for the completion of the procedure.

6. I have read this form and other 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.