SKIN TAG AND MOLE REMOVAL CONSENT FORM

Skin tags are small protruding bits of skin that often grow in the groin area, armpits, neck and eyelids as well as other places on the body. They are harmless, but are often considered unsightly. Skin tags also known as Acrochordons or Cutaneous Papilloma are harmless skin growths appearing usually in the adult years of life among many healthy and normal people. In common descriptions, skin tags are flesh-coloured projections that appear as small pieces of hanging skin growths. Due to the awkward appearance of larger growths, skin tag removal is common and although their appearance may vary a little for individual tags, most skin tags are either smooth or just a little wrinkled, or irregular. The colour of most skin tags is either the same as that of the body flesh (skin) or a little browner than the surrounding skin.

My signature below constitutes my acknowledgment that I am a competent, consenting adult of at least 18 years of age (or my parent or my legal guardian is giving consent on my behalf), and further, that I:

I have been informed to my satisfaction, regarding the nature of the procedure and acknowledge that this procedure is entirely a cosmetic procedure.
I acknowledge that I have been medically cleared by my supervising doctor concerning this procedure and have previously addressed any concerning lesions/moles on my skin.
If the patient is under 18 years of age, incompetent, or unable to give consent then parent or legal guardian should sign instead.

Prior to the performance of the proposed procedure of treatments, I have been educated about the proposed procedure and risks and possible discomforts involved, other methods of treatment, the potential results of not doing the procedure and the known potential complications.

I am a competent consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further:

Pre and post treatment instructions have been explained to me.
I have had the opportunity to ask questions, and all my questions have been answered to my satisfaction.
I declare that while completing the medical questionnaire, I have answered the information related to my personal medical history questions completely and I have not withheld any information.
I must notify the clinician if my medical history changes prior to subsequent treatments.
I consent to clinical photographs being taken of my treated areas for my personal health record only.
There are no refunds for services rendered and/or after a year from purchase and not used.
The treatments I receive here are voluntary and I release KAI LIFE CLINIC, my doctors, nurse and/or my technician from liability and assume full responsibility thereof for this appointment and future appointments
My signature below constitutes my acknowledgment and understanding of all this information.

I hereby authorize and direct the doctors and/or technician to perform the treatment on me.

Patient Name

Patient Signature

Date/Time

Doctor Name

Signature

Date

Witness Name

Witness Signature