Free Skin Lesion and Mole Removal Consent Form Template

Informed Consent for Skin Lesion and Mole Removal

Patient Informed Consent Documentation

Patient and Provider Information

What This Procedure Involves

Skin lesion and mole removal is a common outpatient dermatology procedure performed under local anesthesia. The method used depends on the lesion's size, depth, location, and whether it needs to be sent to a laboratory for analysis. The main removal methods are: (1) Shave excision: the lesion is shaved flush with the surrounding skin using a surgical blade. The resulting wound heals without stitches but leaves a shallow scar. Suitable for raised lesions that appear benign. (2) Punch biopsy: a circular cutting tool removes a cylindrical core of skin. One or two stitches may be placed. Provides a tissue sample for pathology. (3) Surgical excision: the lesion is cut out with a margin of normal surrounding tissue and the wound is closed with stitches. This method is used when the lesion is suspected to be cancerous or when complete removal with clear margins is needed. All tissue removed during this procedure will be submitted for histopathology analysis to confirm the diagnosis.

Tissue Analysis Authorization

I authorize the treating provider to submit any tissue removed during this procedure to a registered pathology laboratory for histopathological analysis. I understand that: (1) The pathology report may take 5 to 14 business days to return. (2) The pathology fee may be billed separately by the laboratory and may or may not be covered by my insurance plan. I should check with my insurance provider. (3) If the pathology report shows unexpected results, including atypical cells or skin cancer, the clinic will contact me to discuss next steps, which may include additional surgery to remove wider margins.

Risks and Possible Complications

Pre-Removal Assessment Findings

Prior to removal, the provider has assessed this lesion clinically and, where applicable, with a dermoscopy device (a magnifying tool used to examine skin lesions in detail). The provider's clinical assessment supports removal for the following reason: [Provider to specify: e.g. patient request for cosmetic reasons / clinical concern for atypical features / ABCDE criteria changes noted / rapid growth]. Removal does not replace ongoing monitoring of other lesions. The patient is encouraged to continue annual full-body skin examinations, especially if they have a history of sun damage, multiple moles, or a family history of melanoma.

Alternatives to Mole Removal

Wound Care After Removal

After the procedure, the patient agrees to: (1) Keep the wound clean and covered with a dressing as instructed for the first 24 to 48 hours. (2) Clean the wound gently with saline or mild soap as directed, and apply the recommended ointment to prevent the wound from drying out. (3) Avoid swimming, soaking the wound in water, or activities that cause heavy sweating for at least 2 weeks. (4) Return to the clinic for stitch removal at [Provider to specify: typically 5 to 14 days depending on the site]. (5) Apply SPF 50 sunscreen to the healed scar daily for at least 12 months to minimize post-inflammatory discoloration. (6) Contact the clinic immediately if the wound shows signs of infection or if the wound edges separate.

Cosmetic Outcome Disclaimer

While the provider will take every reasonable step to minimize scarring and achieve the best possible cosmetic outcome, all skin removal procedures leave some form of scar. The appearance of the scar cannot be predicted or guaranteed. Scar revision procedures may be available but are not included in the cost of this procedure and would be assessed and priced separately.

Right to Refuse Treatment

The patient has the right to decline this procedure. For clinically suspicious lesions, the provider may strongly recommend removal or biopsy, but the final decision rests with the patient. Declining does not affect access to other care at this clinic. The patient is encouraged to schedule follow-up monitoring appointments if they choose not to proceed with removal.

Patient Understanding

I confirm that I have read this consent form or had it explained to me. I have asked questions about the procedure, the removal method chosen, scarring, and the pathology process. All my questions have been answered to my satisfaction. I understand that a scar will remain and that pathology results may take up to 2 weeks to return.

Language Access

If English is not your main language, please ask for an interpreter before signing. This form must be fully understood before you agree to treatment.

Copy of Consent

I acknowledge that I have been offered a signed copy of this consent form for my records.

Patient Authorization

I voluntarily agree to skin lesion removal as described in this form. I authorize tissue to be submitted for pathology analysis. I agree to follow all wound care instructions. I understand and accept the risks, including scarring, and the possibility that further treatment may be required based on pathology results.

Signatures and Verification