Informed consent for photodynamic therapy for actinic keratoses, superficial skin cancers, and other dermatologic indications, covering photosensitizer application, light source, risks, alternatives, and patient acknowledgments.
The Photodynamic Therapy (PDT) 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, photodynamic therapy, pdt, actinic keratosis, skin cancer. 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.
Document Preview
# Photodynamic Therapy (PDT) 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:** ___________ **Treatment Date:** ___________ **Treating Clinician:** ___________ **Treatment area(s):** ___________ --- ## 1. Procedure Description Photodynamic therapy (PDT) is a two-step treatment that uses a topical photosensitizing agent and a specific wavelength of light to selectively destroy abnormal or pre-cancerous cells. **Step 1 — Photosensitizer application:** A topical aminolevulinic acid (ALA) solution or cream (e.g., Levulan Kerastick, Ameluz) or methyl aminolevulinate (MAL) cream (e.g., Metvix) is applied to the treatment area. The photosensitizer is preferentially absorbed by rapidly proliferating and abnormal cells (actinic keratoses, superficial skin cancers, sebaceous glands). The skin must then incubate for a defined period. **Photosensitizer to be used:** ___________ **Incubation time:** ___________ **Step 2 — Light activation:** After incubation, the treated area is exposed to a light source that activates the photosensitizer, producing reactive oxygen species that destroy targeted cells. **Light source planned:** ___________ --- ## 2. Indications **Clinical indication(s) for PDT:** ___________ **Additional indication detail or off-label use note:** ___________