Download st., Ste. - Southeast Texas Urology Associates, LLP

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Southeast Tex s Urology Associates, L.L.P.
755 NORTH 11TH STREET. SUITE P3200
BEAUMONT, TEXAS 77702
TELEPHONE (409) 899-41 11
FAX (409) 899-5670
J. DENTON HARRIS IV, M.D.
JOHN A HENDERSONIV,
STEVEN A. SOCHER, M.D.
MID.
VASECTOMY INSTRUCTIONS
1. ~nclosbd
in this packet you will find a new patient information
sheet, two consent forms, and a set of pre-operative instructions.
2. Pleaselread everything that is enclosed in this packet very
carefu~l~.
3. Fill out and complete the new patient information sheet and the
blue sh'eet. Sign both of the consent forms. Please note that your
wife will need to sign both consent forms.
4. Return[allforms listed above with a copy of the front and back of
your inkurance card. These forms should be in our office no later
than the Wednesday prior to the procedure. Keep the pre and post
operative instructions for your use.
5. We will contact your insurance company for coverage and
benefits. You will be contacted with the amount due. It is to be
paid by the Wednesday prior to the procedure.
6. If your bro&dure is in the morning, do not eat or drink anything
after midnight. If your procedure is in the afternoon, you may have
a smalll amount of clear liquid before 6:OOam. Do not eat or drink
anythirlg after 6:OOam.
7. On the'date of your procedure, report to 755 N. 1lth
st., Ste.
,3200,
8. You wi I need to have someone come with you to stay and then
drive you home.
9. Do not :take any aspirin or blood thinner ten days prior to the
procedirre.
Should you have any questions regarding these
instructions, do not hesitate to call our office at
(409) 899-4111.
~ ~ ~ o i n t r hDate:
ent
4
Arrival !me:
&
Doctor:
Southeast Texas Urology Associates, L.L. R
J. DENTON HARRIS IV,M.D.
JOHN A. HENDERSON IV, M.D.
755 NORTH 11TH STREET, SUITE P3200
BEAUMONT, TEXAS 77702
TELEPHONE (409) 899-411 1
FAX (409) 899-5670
STEVEN A. SOCHER, M.D.
Vasectomy Cancellation Policy
Dear Patient:
have reserved a surgery slot for your vasectomy. If you need to change your
appointment date for any reason, we require 72 hours notice. Patients who fail to give
notice will not be rescheduled until we receive a cash deposit. We require $1 50 to be
placed on the schedule again. This money will go towards your procedure. Should you
cancel again, the deposit will not be refunded.
Southeast Texas Urology Associates
PRE-OP INSTRUCrrONS
1. The night $efore the vasectomy, please shave or remove most of the hair on the scrotnm.
ihl
3. Bring an a etic supporter (Jock Strap) with yon to the facility.
4. Yon must iring someone to drive you home after gour procedure is finished,
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POST-OP INSTRUCTPONS
1. Go home d lay down through the day. Place an ice pack on scrotum. Stay offyour feet as much as
P b I e thnmgh d
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y two. AppIy an ice pa& to operative site for 12 horns after the promh~?.
2. Dressing daybe removed on day two and you can shower or bathe as needed, Please soak in warm
wikfer 2-3tides d a y for 3-4 days.
3. wear scmfbI support for kvo m three days You can wear the support longer if it i s more rnzforhble
than yam&
undemear.
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4. No heavy ltfting or strenuous exercise for 7-10 days followinggour vasectomy. You should be able to
retmnto world on (lay &ee.
5. Take all mkdrcations as presm'bed. Do not dtim while taking pain medications.
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6. Y c m m a y ~ a ~ s n m ( m t 0 f b l e ~ g t h a t m y s e e p ( h m n g h g o m ~ e ~ m g a l l z e m t h e ~
to second d q i If this occm, place gauze or tissue and apply gentle steady pressure for threeto five
m*nutes.
7.Fo~oPPingl
hvasectomg,,scrotmnandpenismaybecomebnrise& ThiswiIlimpmvewithtime.
.
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8. There will i e some swellingfollowing the vasectomy. Anything twice the norma1 size or appears to be
infixtd, please calI the &ice.
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9. Infamo~smay be resumed at your discretion, but it is suggested you lefrain until the incision is
ei
comp1eteIy heaIed_
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"p, I'
10. Remembek to bring a specimen to the office six to eight weeks following yw vasectomy. Specimen
shouId be collected in the morning in ffie co-rs
provided at om &ce. Containers maybe i,icked up
at the receptionist desk in our office. (Lf specimen is collected in a condom, please empty it into the
specimen container.) Once collected, keep specimen at room temperature and bring the specimen to the
&ce as soon as possibIe. Please call to make sure that there is a doctor in the office before yon bring in
your specimen.
d
**Yonmi b , required to have two conseenfipe negative specimens before y6u will be deased fmm
our doctors. Until the sperm are completely absent from the semen, a pregnancy can be initiated. It
is very important to continue to use a form of birth control until you have been released from our
doctors.**
CONSENTTO S-TION
OPERATION
(SURGICAL VASECTOMYJ
NOT TO BE STeRlLaED WILL NOT RESULT IN THE
OF ANYSPROVIDED BY PROGRAMS OR PROJECTS-
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I have been grven
t&e followingM m a t i m :
of SferitizafionProcednre
vasectomy is minor surgical P r ~ mwhich
e arn be perforlued in the dactor's ofEceor c h i c under a
local anesthetic and iwoIves clipping the cords in the scrotum. The surgery takesapproximately twenty
minutes and iworves making s m d incisions on each side of the scrotum The sperm duct is then M and
sealed, and the sealed ends of the duct are then retmned to the scrotnm. To reduce the pos4WQ that the
cat tubes may ,rejoin,a 1/4 & 54 inch piece of cord may be removed during the surgery. The stitches used
during the pro/cedure win dissolveby themselves.
2 ~esedpti4
of the ~ttmdant~ismmfimandRisks
A matl amo+ of oozing blood (mougIi to stain me dressing), some discomFnt and mild me1Iing in the
a m ofthe incision are not armsuatand &odd subside within seventy-twohours.
Very rarely, a i d blood vessel may escape into the s m h m and continue to bleed to ha clot. A
small dot wiIl be absorbed after a time, but a large me is painfbl and usually reqcnies reopeningof the
scrotum and drainage of the clot. Hospitalization and a general anesthetic is usualIy required for this
n
pwOseFor
a week fo owing the vasectsmp*sex should be eliminatad Stnmnous exercise(fir exampre, climbing
ladders, riding motorbikes, bicycles, playing tennis, etc.) shouId be avoided and nothing that weighs over
a few pounds should.be lifted. The reason for fhis is that engaging in these activities sometimes r e d &in
c~mptications~
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This surgical brocedure is not arways 100% e f f d v e in prevedng pregnancy, because on rare occasions
fhe cut m& ofthe cord may rejoin; but this only occuts at a rate of I in every 600vastxtcmies
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a
Do not have nkpmtectcd intercourse nnfit
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3. Beurnto
Ejrpected
have bad ttao & e m f k e samples.
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The vasecfomi is done in the docfor's office m chic in approxhmfelytwenty lnirufes using 10081
anesthetic; it iS a simple?safe method to prevent unwanted pregnancy Recovery is @ck the patient can
&y
return work in fwo days (over a weekend).
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sdactiv&,@esensrnvrty
.. . ,md the pradnction o f w e hormones are not admmely & ' In
&ct, thefieeddm from fear of producing unwanted cliiIdren ma geatly improve the mutual enjoyment in
your sexuat reIahons. You may find fiat your desire for sexual expressionsbecomes more spontaneous
and more fiequent
PAGE 1of 3
PLEASE RETURN
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4. Counseling honcerding Alternate ~ethods
is merely to space pregnancies, or if you have even the slightest
that you might want to have more children in the future, then a
suit your purpose, and should not be considered.
Other methods o
Pntrauterine
contraceptive
birth control which may be used are: oral contraceptives (the pill),
(IUD), diaphragm, condom, aerosol contraceptive foam, rhythm, and
and jellies.
a vasectomy is not for you, yet you and your wife are sure you
children or more children, a;laparoscopy (tuba1 ligation) for you=
method. This is a permanent method of Birth control and is a
procedure.
do not vant to
wife is an
.
.
h
A vasectomy shou d have no adverse effects on your sex life.
Any problems which develop
in relation to hkvihg sexyal interconrse would result from psychological. rather than
physical causes. After a vasectomy, a man's hormones remain operative and there is no
noticeable diffe ence in his ejaculate, because sperm make up only a tiny part of the
semen. The s p e d cannot come out after the cord is clipped. Like other de3d body cells,
the sperm disintLgrate and are discharged from the body as wastes.
some men, even kI
owing these .facts, are still anxious about what a vasectomy will do t,o
!
their sexual,per&ormance. These men should,not have yasect.omies,because worrying about
sexual performande is iikeiy to impair a inan's abil'ity to have an Prection.or ejaculate,
even though the droduction of sperm and male hormdnes continues.
*
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. A' viaeritomy
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i s n It the answer to a problem of sexual maladjustment or failing sexual
pokers. Therefoqe, if you -aregetting a vasectdmy in hopes or improving your wife's
-attitude towardqax or to increase yoor sexual powers, you are likely to be disappointed.
on the other hanq, the freedom from fear of producing unwanted children may improve
greatly the mutnah enjbyient f n ybuir,sexual relitibns.
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5.
Effect and Imbact of Sterilization
ThB 'purpose is to
'canho'tbe fertili
the:.,testes
but ar
%he:amount of the
,aftervasectomy.
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,
..
,.
sperm from entering the:seminal fluid s o that the female egg
to intercourse. ': ~&rm'cells continue to be produced in
the body as wastes i y t e a d , o f in the semen. However,
dnrihg intercbbsse ddes not decrease more than 5%
.
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&teetomy is to bh considered a permanent birth cbntrol procedure, because at present
these operations +an be reversed so that pfegnancy follows only 15% of the time.. Although
'chis surgical prohedure must be thought of as completely'irreversibledbd producirig
permanent steriliey (i.e., there is a loV incidence of failure) thd procedure is not
alveys 100% &f feciive
.
I.
occasionally one effect of the vasectomy is that the skin of the scrotum and base of
the penis turn
and blue. This is not painful an8 lasts only a few days and
.dis'appears
6.
~nquiries
Any inquiries I h
fully answared .
the sterilization procedures described in this document were
PAGE 2 OF 3
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7. Withdrawal
I
Consent
I realize I am
any time prior
and without 10s
entitled.
:ee to withdraw or withhold my consent to the sterilizatibn procedure at
the sterilization procedure being performed without prejudicing my care
of other project or program.benefits to which I might otherwise be
1 have read all f the above and do voluntarily consent to sterilization by this surgical
procedure. I rc lize the sterilization procedure may not be performed sooner than
seventy-two hou: following my signing of this consent form.
I certify that : am 21 years of age or older and legally and mentally competent.
BIRTHDATE:
DATE :
TIME:
.
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SIGNATURE OF PA1 ENT
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AUDITOR-WITNESS
.
. .
ESIGNATED BY PATIENT
.
SIGNATURE OF -PHY CCIAN OR PERSON
OBTAINING CONSEN
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PT.FASR
RF'lTlRN
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'DISCLOSUREBND CONSENT
MEDICAL BETD SURGICAL PROCEDUES
THIS $'OH4 IS DESIGNED TO COMPLY WITH THE REQUIREMENTS
PROMULGATED BY THE TEXAS MEDICAL DISCLOSURE PANEL
I
:
TO .TEEPATImT.
:.
You
have the r i g h t , as a p a t i e n t , t o be informed about your condition
and tlie recoimiended s u r g i c a l , medical, o r diagnostic prockduie t o be used so t h a t you
may make the d e c i s i o h whether o r not t o undekgo t h e procedure a f t e r knowing t h e r i s k s
a d h a z a r d s W o l u e d . This disclosure i s not meant t o scare or alarm you, i t i s
siniply an eff0i-i: t o make y o u ' b e t t e r informed so you may g$ve 6 r withhold your konkent
$0 t h e proceduke.
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I (We) v o l u n t d i l y request D r . ' J. Denton Harris I V , o r Dr. John A. Henderson Tv, o r
D r . Steven A. $&her a s rdy physician, and such associates, technical a s s i s t a n t s
and :other h e a l t h c a r e providers a s they may deem necessary, t d t r e a t my condition
t o me a s f e r t i l i t y anxiety.
.
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.
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..
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t h a t the following s u r g i c a l , medical, and/or diagnostic procedures
I (we) voluntaPil~"'consentand authorize the foilowing
my physician may discover 6 t h e r o r d i f f e r e n t c o i ~ d i t i ? ~which
S
d i f f e r e n t procedures than those planned. I (we) authorize'.my
t e c h n i c a i a s s i s t a n t s and other health care providers.
which a r e advisable i n t h e i r professional-judgement.
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necessary.
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the use of blood, a n d bldod produets as deemed.
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I:.(we) u n d e r s t -nd t h a t no warrarity or guarantee has been made ' t o me a s t o r e s u l t
or cure.
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iI
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J u s t as t h e r e ~ a be
y r i s k s and hazards i n continuing m y
conditionwithout
treatfient, t h e f e axe a l s o r i s k s and hazards r e l a t e d t o the performance:.of t h e
surgical, medical, and/or diagnostic procedures planned f o r me. I (We) r e a l i z e . '
s u r g s c a l , medical, aad/or diagnostic procedures i s t h e p6tentiaL f o r
c l o t s i n veins afld lungs, hemorrhage, a l l e r g i d reactioh, apd even
death. I (We)' a l s o r e a l i z e t h a t t h e following r i s k s and hazards m a y occur i n
wit,::tbis p. .a.r. t i..c u l a r procedure: l o s s of t e s t i c l e s , f a i l u r e t o produce
conn'ection
.
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permanent r e s u l t s , p o s s i b i l i t y increased r i s k of developing g i o s t a t e cancer.
d
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I (wej undersf nd t h a t anesthessa iTivolves a d d i t i o n a l r i s k s and hazards but I (we)
request the u s e of a n e s t h e t i c s f o r t h e r e l i e f and prorecCion from pain during t h e
planned and a t l d i t i o n a l procedures. I (We) r e a l i z e t h e anesthesia may have t o be
changed possi.b$y without explanation t o me (us).
Page 1 of 2
ni - - - n-&..-
,
I (we) underst
including resp
Other risks an
from minor dis
that other ris
headache and c
nd that certain complications may result from the use of any anesthetic
ratory problems, drug reaction, paralysis, brain damage or even death.
hazards which may result from the use of general anesthetics range
omfort to injury to vocal cords, teeth or eyes. I (we) understand
s and hazards resulting from spinal or epidural anesthetics include
ronic pain.
I (we) certify this form has been fully explained to me, that I (we) have read it
or have had it read to me, that the blank spaces have been filled in, and that I (we)
understand its zontents.
I (we) have re 9 literature and pamphlet supplked by office.
DATE:
TIME:
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PATIENT'S WIFE ; SIGNATURE
WITNESS :
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SIGNATURE
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ADDRESS ( STREEI OR PO BOX)
CITY, STATE, ZI
CODE
PIiEaSE RETURN
Beaumont Pathology Associates
2830 Cdder, ~ e p t opathology
f
Beaumont, Texas 77702
409-899-7150
May 11,2009,
Southeast Texas Urology Associate, LLP
755 North 11' Street, Suite P3200
Beaumont, Texas 77702
~6
as
RE:
deferens billing agreement between Southeast Texas Urology, Beaumont
Pathology Associates and Patient
,
There is a separate charge for pathology when a vasectomy is performed. Insurance will
be filed. If deductibles have not been met or the service is not a covered pr-wedure,the
patient will be billed $90.00. Patients with no insurance will be responsible for payment
up front before the procedure is performed. The fee is $90.00 and it will be collected by
Southeast Texas Urology.
Should you have any additional questions, please do not hesitate to contact me.
Sincerely,
Dr. Kathryn Bornrner
Beaumont Pathology Associates