Adult Benign Skin Lesion Removal Consent Form

1. Information the form asks you to provide

• Your name, address, email and telephone number.
• Allergies or sensitivities, including medicines, dressings, latex, adhesives or local anaesthetic.
• Blood-thinning medicines and any prescribed, over-the-counter or herbal medicines.
• Pregnancy or breastfeeding, diabetes, poor circulation, bleeding disorders, reduced immunity or anything that may affect healing.
• Previous slow healing, raised or keloid scarring, skin cancer, melanoma or a suspicious skin lesion.
• Infection, broken skin, rash or inflammation near the treatment area.
• Any recent change in the lesion’s size, shape or colour, or unexplained bleeding, crusting or ulceration.

2. Lesion and clinical assessment

Gemma records the lesion location, how long it has been present, your concerns, the clinical assessment and any dermoscopy findings.

• Suitable for cosmetic treatment
• Treatment deferred
• Further clinical evidence required
• GP or dermatology referral advised
• Treatment declined

3. Proposed treatment

The form records the number and location of lesions approved for treatment, the proposed procedure and whether local anaesthetic is planned.

• Cryotherapy
• Curettage
• Shave removal
• Snip removal
• Another agreed procedure

4. Common treatment risks

Benign skin lesion removal may cause temporary pain or discomfort, redness, swelling, bruising, bleeding, blistering, scabbing or weeping. Other possible risks include infection, delayed healing, changes in skin colour, scarring, altered sensation or numbness, damage to surrounding tissue, incomplete removal and recurrence. More than one treatment may be required, and a particular cosmetic result cannot be guaranteed.

5. Cryotherapy information

Cryotherapy uses controlled freezing to destroy selected tissue. It may cause stinging or burning, redness, swelling, blistering — including a blood-filled blister — weeping and scabbing. Less common risks include infection, delayed healing, permanent lightening or darkening of the skin, hair loss in the treated area, scarring and temporary or permanent altered sensation. Treatment may be unsuccessful, the lesion may recur, or further sessions may be required. Cryotherapy destroys the tissue, so it cannot later be sent for laboratory analysis.

• You will be asked about severe reactions to cold, Raynaud’s phenomenon, cold urticaria, cryoglobulinaemia and other cold-related conditions.

6. Curettage, shave and snip removal information

These procedures physically remove the selected lesion and may require local anaesthetic. Possible effects and risks include discomfort from the injection, bleeding, bruising, swelling, infection, delayed healing, wound breakdown, scarring, an indentation or change in skin contour, changes in skin colour, altered sensation, incomplete removal and recurrence. Further treatment may be required, and the final cosmetic appearance cannot be guaranteed. If the diagnosis is uncertain or laboratory examination is clinically required, treatment may be deferred and referral advised.

7. Local anaesthetic information

If local anaesthetic is used, the injection may cause temporary stinging, discomfort, bruising, bleeding or swelling. Temporary numbness is expected. Less common risks include infection, fainting, palpitations, an allergic or adverse reaction, prolonged altered sensation, nerve injury or local anaesthetic toxicity.

8. Patient consent declaration

You will be asked to confirm that you are aged 18 or over; the information you have provided is complete and accurate; the purpose, expected benefits, material risks, limitations and reasonable alternatives — including no treatment — have been explained in a way you understand; and you have had time to ask questions and consider your decision.

You may defer treatment or withdraw consent at any time before the procedure begins. Further treatment may be required, lesions may recur and the cosmetic outcome cannot be guaranteed.

• Questions asked and answers given are recorded.
• Aftercare information and how to contact the clinic are confirmed.
• Your final consent applies only to the procedure or procedures recorded on your form.

9. Photography — a separate choice

Photography consent is separate from consent to treatment. Refusing promotional photography will not affect your care. Clinical photographs are stored securely with your treatment record.

• Consent to confidential clinical-record photographs: yes or no.
• Promotional use: anonymised close-up images only, identifiable images, or no promotional use.
• Promotional consent may be withdrawn before publication. Images already published online may have been copied or shared by others and cannot always be fully removed.

10. Practitioner treatment record

After treatment, Gemma records the procedure performed, cryotherapy or local anaesthetic details where relevant, haemostasis, dressing, immediate aftercare, any complication or adverse reaction, and follow-up or safety-netting advice.

11. Privacy and data protection

You Little Gem Clinic uses personal and health information to assess suitability, provide safe care, maintain accurate clinical records, arrange follow-up and meet legal and professional obligations. Health information is stored securely, accessed only when necessary and retained in line with the clinic’s retention policy. Information is shared only where there is a lawful and clinically appropriate reason.

You will be asked to confirm that you have been given access to the Patient Privacy Notice and understand how your information will be used.