Debridement - Pre-Procedure Patient Information

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  • For our Diabetic patients, please fill out the following:

  • Acknowledgement of Risks

  • Please Sign or Initial
  • Please Sign or Initial
  • Please Read and Respond

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  • Procedural Risk Acknowledgement

    Risks of the procedure(s) include (but are not limited to) the following: 1. Anesthetic or sedation complications including death 2. Infection 3. Prolonged effects of anesthesia or sedation
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  • Payment Acknowledgement

    An $800 surgery deposit will be due prior to drop off. Payment is due in full at pick up. Payment may be made in the form of cash, personal check, VISA, or MASTERCARD. A fee of $35.00 will be added to payable charges for returned checks.
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