Dr. Suneel Chilukuri has fully explained, in terms clear to me, the effects and nature of the procedure(s) to be performed, the product(s) to be used and foreseeable risks involved. Complications that can occur with any dermatologic procedure include, but not limited to, worsening or unsatisfactory appearances, bleeding, bruising, poor healing, pain, scarring, recurrence of original condition, pigment changes (which could be permanent), blindness, numbness to the area or infection.
I have been given the opportunity to ask any questions regarding the matters covered in the preceding sentences, and these questions have been answered to my satisfaction. I consent to the administration of anesthetics by or under the direction of Dr. Chilukuri and to the use of such anesthetics and medications, as he may deem advisable in my case.
I agree to the instructions given to me by Dr. Chilukuri to the best of my ability before, during and after the above named procedure(s).
I hereby give permission to Dr. Chilukuri or any medical assistant designated to take photographs to enhance the medical record and for diagnostic purposes.
