Informed consent for Mohs micrographic surgery for skin cancer, covering procedure stages, reconstruction options, risks, alternatives, and patient acknowledgments.
The Mohs Micrographic Surgery Informed Consent is a ready-to-use healthcare & wellness template you can send for signature in minutes. It is written for 1 signer (patient) and, by default, expires 30 days after it is sent if left unsigned. It covers consent, dermatology, mohs surgery, skin cancer, surgical, dermatologic surgery. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Mohs Micrographic Surgery Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Patient Name:** ___________ **Date of Birth:** ___________ **Procedure Date:** ___________ **Mohs Surgeon:** ___________ **Tumor site (anatomical location):** ___________ **Biopsy-confirmed diagnosis:** ___________ --- ## 1. Procedure Description Mohs micrographic surgery (MMS) is a specialized surgical technique for the removal of certain skin cancers, most commonly basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). It offers the highest cure rates of any skin cancer treatment modality for appropriate tumors (approximately 99% for primary BCC, 94–97% for primary SCC) while maximizing preservation of healthy surrounding tissue — a critical advantage on functionally and cosmetically sensitive areas such as the face, ears, hands, and genitalia. **How the procedure works:** The surgeon removes the visible tumor plus a thin margin of surrounding tissue. The excised tissue is processed and examined under a microscope while the patient waits. A complete map of the surgical margins is prepared. If cancer cells are identified at any margin, the surgeon removes an additional thin layer only from that precise location. Stages continue until the margins are completely clear of cancer. The average number of stages is 1.5–2, but some tumors require more. **Estimated number of stages (surgeon estimate based on clinical presentation):** ___________ --- ## 2. Indication for Mohs Surgery Mohs surgery is selected when tumor characteristics favor this technique, including: - Location in a cosmetically or functionally sensitive area where tissue conservation is important - Aggressive histologic subtypes (morpheaform, infiltrative, perineural involvement, high-grade SCC) - Large tumor size - Recurrent tumor after prior treatment - Poorly defined clinical margins - Immunocompromised patient