AMERISKIN ®

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"Bringing Personalized Skin Care to the People of America"

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CONSENT FOR SKIN CANCER SCREEN

Name:_____________________________ Age:______ Sex:____

Street Address:_____________________ Telephone:___________________

City:__________________________ State:_____ Zip Code:_______

I, the undersigned, release AMERISKIN ®, Healthy Nebraska, Inc. and their 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 AMERISKIN ®, Healthy Nebraska, Inc. or their 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:_____________


AMERISKIN ® is a public-private effort in healthcare services related to educating Americans about proper skin care as well as the prevention, diagnosis and treatment of skin conditions, including skin cancers. If you undergo a skin biopsy, the skin specimen may be sent to AMERISKIN ® for processing, evaluation, diagnosis, and inclusion in its database.

For more information about our services or to send skin biopsies to us, contact

AMERISKIN ®

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500 West Leota Street Suite 200
North Platte, Nebraska 69101

Byron L. Barksdale, M.D.
Phone: 308-532-4700

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