Patient Informed Consent to Treatment

2. The nature and purpose of the treatment has been explained to me, and any questions I have regarding this treatment have been answered to my satisfaction.

3. I understand that the treatment may involve risks of complication or injury from both known and unknown causes, and I freely assume these risks. Possible side effects to the treated area can include mild redness of the skin, irritation, local swelling, mild discomfort or tenderness, dry skin, lightening or darkening of the skin, and a very small risk of keloids or scarring. Infections due to bacterial contamination may occur if after treatment care instructions are not followed.

4. Alternative means of treatment and their risks and benefits have been explained to me and I understand I have the right to refuse the treatment.

5. No guarantee, warranty or assurance has been made to me as to the results that may be obtained, and I understand that individual response to treatment will vary.

6. I certify that I have read this entire Informed Consent and that I understand and agree to the information provided in this form. I certify that I am a competent adult of at least 18 years of age, or, that if I am a minor, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before treatment. This Informed Consent is freely and voluntarily executed and shall be binding upon my spouse, relatives, legal representative, heirs, administrators, successors and assigns.

7. I understand that patients with Herpes Simples Virus (cold sores) must be premedicated.

8. I understand that more than one treatment may be needed to obtain desired results and that I am solely responsible for after treatment care.

9. I have received and understand Koger Dermatology after care instructions.

The foregoing constitutes written disclosure by Koger Dermatology to the undersigned of the risks and expected recovery and is fully understood and that it was preceded by an explanation by the medical staff.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.