Consent Forms | Same Day Podiatry L

Nail Surgery Consent Form

First name

Last name

Birthday

Medical History

Medications

Allergies

Surgery Proposed

Date and time

:

Benefits: To remove ingrown to nails, reduce pain, reduce infection risk and improve quality of life.

Risks: Phenol burn, post-operative pain, bleeding, ulceration, anaphylaxis, paresthesia/nerve damage, nail regrowth, treatment failure, sepsis, tissue loss

Additional Risk Factors Specific To Patient

Anesthetic - Mepivacaine Hydrochloride 3% Plain Dose

Phenol 89% applied for 2 minutes

Clinician

Photo

I confirm that I understand in full the contents of this form

I consent for the podiatrist to undertake the listed surgical proceedure

I consent for the Podiatrist to administer local anaesthetic

I accept the benefits and risks as outlined within the form

I understand that any payments made are not refundable

I understand the risks of treatment failure and acknowledge that any repeat procedures are chargable

I agree to the full terms and conditions available at www.samedaypodiatry.com/policies

I believe that all aspects of the proposed treatment has been explained to me clearly and I do not have any further questions

If applicable, I understand that the additional risk factors put me at greater risk of complications, and that I am making an informed choice to accept these risks knowing the potential consequences.

I consent for photography to be taken

I understand my right to withdraw before the proceedure takes place.

I understand that failing to provide the clinician with the correct personal details can put my health at risk

I confirm that I have read and understood all the information provided in this form. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I understand the nature of the procedure, its risks, benefits, and any alternative options. I understand that in the event of an emergency, or unexpected findings during the treatment that additional procedures may need to be conducted either during or after the surgery which have not been mentioned in this form. I consent to proceed with the nail surgery under the terms outlined above

Signature