Wound Debridement Informed Consent

# Wound Debridement Informed Consent > **Important — not medical advice.** For use by a licensed provider; tailor to the patient, your protocols, and state law. **Date:** ___________ **Healthcare Organization / Wound Care Center:** ___________ **Performing Provider:** ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medical Record Number:** ___________ --- ## 1. Wound Description **Wound Location:** ___________ *E.g., right plantar heel, left lateral malleolus, sacral pressure injury, right lower leg venous ulcer* **Wound Type:** ___________ **Wound Stage or Classification (if applicable):** ___________ *E.g., Stage III pressure injury; Wagner Grade 2 diabetic foot ulcer; NPUAP Stage IV* **Wound Dimensions (approximate):** ___________ *Length × width × depth in cm; note tunneling or undermining if present* **Wound Duration:** ___________ *E.g., "Present for approximately 6 weeks"* ---