Wart Removal Form Name First Name Last Name How long have you had warts? Weeks Months Years Have they recently worsened? Yes No Do you have any immune compromising diseases such as HIV (AIDS)? Yes No Untitled* I acknowledge that I have read the consent form and understand it.I have been adequately informed with the risks and benefits of this treatment . By ticking the box, I agree to proceed with the procedure. Staff signature ___________________ Patient signature ___________________ PhoneThis field is for validation purposes and should be left unchanged.
