Patient CONSENT for head to toe full skin examination
Full skin exams are best conducted with patients wearing neutral coloured plain underwear.
A modesty gown and sheet are provided for patient’s comfort.
A female chaperone is present at all full skin examinations.
Patients may have skin lesions in areas covered by their underwear which are not evident to the examining clinician.
Patients should make the
examining clinician aware of such lesions which may then be examined and photographed if required.
Should patients NOT wish these lesions to be examined or photographed no clinical responsibility shall be taken for their management.
Please indicate below your intention on these lesions.
Consent:
I have been informed to my satisfaction about the process of full skin examination and any digital clinical photography and diagnostic skin ultrasound
which may be warranted in the management of skin lesions detected at this full examination including areas concealed by my underwear and consent
to SKIN SURVEILLANCE clinicians and staff performing such full examination, clinical photography , diagnostic skin ultrasound and total body
photography as considered appropriate to my clinical skin status.
Name: ................................................................................................................................................... Date of birth: ...................................................
SIGNATURE:........................................................................................................................................... Date: ................................................................
Witness:.............................................................................................................................................
Proviso on concealed lesions:
I am aware / unaware of skin lesions situated in body areas concealed by my underwear and do not consent to the examination or clinical photography,
diagnostic skin ultrasound or inclusion in total body photography of these particular lesions.
I accept that in this circumstance I hold full responsibility for any clinical outcome which these concealed lesions may proceed to.
I declare that I do not and shall not hold Skin Surveillance and its clinicians and staff responsible in any manner whatsoever for the clinical outcome
which these concealed lesions may proceed to.
SIGNATURE:.........................................................................................................................................date.................................................................
Witness:.............................................................................................................................................
Acknowledgement diagnosis accuracy limitations: It has been explained to me and I accept that head to toe full skin examination, HD digital skin
surface microscopy (dermoscopy) and high resolution skin ultrasound are aids to the diagnosis of skin cancer which may not however have 100%
diagnostic accuracy.
SIGNATURE...........................................................................................................................................date.....................................................................
Witness.................................................................................................................................................