Before Your Procedure

Treatment
Consent Form

Please review and complete the consent form below prior to your scheduled procedure. If you have any questions about the information requested, please call our office at (561) 561-SKIN (7546).

Please read carefully: This consent form is a general document. Procedure-specific consents will also be provided and reviewed with you on the day of your treatment. Please do not hesitate to ask Dr. Rotter or our staff any questions you may have.

Patient First Name *

Patient Last Name *

Date of Birth *

Today's Date *

Planned Procedure *

Consent Statement

I consent to evaluation and treatment by Dr. Steven Rotter and the staff of Exclusive Dermatology. I understand that dermatologic procedures involve potential risks, which have been or will be explained to me. I have had the opportunity to ask questions and my questions have been answered to my satisfaction. I understand that I may withdraw this consent at any time prior to the procedure.

Patient Signature (Type full name to sign) *

Additional Notes or Questions

By submitting this form, you acknowledge that the information provided is accurate and complete to the best of your knowledge.

Ready to Schedule Your Consultation?

Contact Exclusive Dermatology in West Palm Beach today. Dr. Rotter and the team are here to help you look and feel your best.

Call (561) 561-SKIN (7546) Request Online

500 S. Australian Ave, Suite 205 • West Palm Beach, FL 33401 • Mon–Fri: 9am–4pm

TreatmentConsent Form

Ready to Schedule Your Consultation?

Treatment
Consent Form