CUBA SKIN INSTITUTE

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www.cubadermatology.com

"Bringing Personalized Skin Care to the People of Cuba"

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WHO SHOULD EVALUATE OR BIOPSY YOUR SKIN?

CONSENT FOR SKIN CANCER SCREEN

Name:_____________________________ Age:______ Sex:____

Street Address:_____________________ Telephone:___________________

City:__________________________

I, the undersigned, release CUBA SKIN INSTITUTE and its participating skin examiners, from any and all liability arising from or connected with my skin cancer screening examinations. 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. 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 diascopy 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 CUBA SKIN INSTITUTE or its 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 areas I specifically bring to the attention of the skin examiner.

I HAVE READ AND UNDERSTOOD THE ABOVE PARAGRAPHS.

Signature:_____________________________ Date signed:_____________

Witness:______________________________ Date signed:_____________


CUBA SKIN INSTITUTE is a non-profit humanitarian public-private effort in healthcare services related to educating people about proper skin care as well as the prevention, diagnosis and treatment of skin conditions, including skin cancers. Ongoing national research furthers our efforts to continually improve skin disease diagnosis and treatment.

For more information about our services, contact

CUBA SKIN INSTITUTE

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