Consent for Treatment

Please sign and/or place your initials in the spaces below

I give my permission for the doctors and staff of Hecker Dermatology Group, P.A. to treat me, including any
biopsy procedure(s) as deemed necessary in the exercise of their professional judgment. I will discuss any
procedure(s) with the doctors and staff first and ask any questions I may have concerning these procedure(s).

I understand that medical care requires my cooperation, and I will follow my doctor’s orders and
prescriptions. If indicated, I will make and keep appointments for follow-up care and call the office to note
any changes or concerns in my condition.

I authorize my physician and Hecker Dermatology Group, P.A. to take photographs/video tape or by
other similar means to record my surgery/procedure(s). I understand that reproduction or publication of said
photographs and recordings will be used for the purpose of medical/scientific/diagnostic study and research,
education, before and after surgical portfolios and/or documentation for my medical record.

I understand that the photographs and recorded material may include appropriate portions of the
body to demonstrate surgery/procedure(s) and that every effort will be made to protect the patient’s
identity in those materials.

I further acknowledge that all recorded media obtained is the sole property of Hecker Dermatology
Group, P.A.

I hereby certify that I have read the foregoing CONSENT and full understand the contents thereof.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

AUTHORIZATION AND RELEASE

I have read and understand the medical consent forms that have been provided to me by the
doctors and staff of Hecker Dermatology Group, P.A.

I authorize my doctor to release any information, including the diagnosis and the records of any
treatment or examination rendered to me or my child during the period of such medical care to third-party
payers, including Medicare.

I authorize and request that my insurance company, in lieu of reimbursing me directly, pay to the
doctor or the medical group any benefits for services rendered.

I understand that my medical insurance carrier may pay less than the actual bill for services. I agree
that I may be responsible for payment of all services rendered on my behalf or my dependents.

I understand that I may be billed by an outside laboratory for work that is performed in this office, if
my insurance company does not have a contracted lab or facility, or if services are not covered by my
insurance company.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.