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CONSENT FOR SKIN CANCER SCREEN
Name:_____________________________________________ Age:______ Date of Birth:______________ Gender:____
Street Address:_____________________ Telephone number:___________________
City:__________________________ State:_____ Zip Code:_______
I, the undersigned, release Pathology Services, P.C. and its participating skin examiners, from any and all liability arising from or connected with my skin cancer screening examination. By voluntarily participating in this skin cancer screening, I recognize and accept all risks associated with it. I understand that the skin examiner will only screen me for skin abnormalities using only a visual examination. Further, I understand that the gold standard for skin cancer diagnosis is a tissue biopsy and is not a part of this skin screening examination. I understand that the findings from my examination will be orally reported to me at the conclusion of my examination along with recommendations, if any, for further followup or evaluation by my personal doctor and that I am wholly responsible for any expenses involved in following these recommendations. I also understand this is a preliminary skin cancer screening and does not constitute a complete skin cancer examination. I also understand if I have any further questions and/or concerns that the screening may have prompted, they should be discussed with my doctor and if I do not have a doctor, best efforts by Pathology Services, P.C., will be made during my visit to help me find a healthcare provider. It is understood that:
1. This skin cancer screening is not as complete nor does it substitute for a full skin cancer examination, including the use of dermoscopy or tissue biopsy, by my personal physician or healthcare provider.
2. The responsibility for any follow-up examination to check abnormalities found during this skin cancer examination is mine alone and not the responsibility of any physician or healthcare provider at Pathology Services, P.C., its participating skin examiners, or their affiliates.
3. I also understand the responsibility for initiating a follow-up examination to confirm results of this screening and for obtaining professional medical assistance is mine alone.
4. I understand that a total body skin cancer examination will not be performed. The only skin areas being examined during this skin cancer screening exam are the one or two skin lesions I specifically bring to the attention of the skin examiner.
5. I understand short forms, including insurance, HIPAA and Privacy forms, will need to be filled out, completed and signed by me, or my authorized representative, prior to my skin being examined.
6. I understand there will be a professional office visit charge for this skin screening examination.
I HAVE READ AND UNDERSTOOD THE ABOVE PARAGRAPHS.
Signature:_____________________________ Printed Name:_______________________________ Date signed:_____________
Signature of parent, guardian or authorized representative:_________________________________ Printed Name:___________________________ Date signed:____________________
Name:_______________________________ Date signed:_____________
NEBRASKA MELANOMA CENTER ® is a public-private effort in healthcare services related to educating Nebraskans about proper skin care as well as the prevention, diagnosis and treatment of skin conditions, including skin cancers. If you undergo a skin biopsy, the skin specimen may be sent to NEBRASKA MELANOMA CENTER ® and its affiliate, Pathology Services, P.C. for processing, evaluation, diagnosis, and inclusion in its database.
Having your skin biopsy specimen(s) sent to Pathology Services, PC. is not required to avail yourself of the resources of NEBRASKA MELANOMA CENTER ®. If your healthcare provider sends your skin biopsy specimen elsewhere, NEBRASKA MELANOMA CENTER ® would appreciate a copy of your pathology report to include its diagnosis in its Nebraska cancer registry. Ongoing national research furthers our efforts to continually improve skin disease diagnosis and treatment for Nebraskans.
Byron L. Barksdale, M.D.
NEBRASKA MELANOMA CENTER ® is a service mark of Pathology Services, P.C.
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