Tolnitch Surgical Associates, PA |
|
Lisa Tolnitch, M.D., F.A.C.S. |
Telephone: 919-782-8200 Fax: 919-781-0440 |
||
IN-OFFICE PROCEDURE CONSENTPATIENT'S NAME: ______________________________________________________________________________ PROCEDURE: _________________________________________________________________________________ ______________________________________________________________________________________________ DATE OF PROCEDURE: _______________ TIME OF PROCEDURE: _______________ I, _______________________________________ consent to the above mentioned procedure. I understand that it is elective. I understand the possible risks and complications. I understand that the doctor may elect to place a tiny, permanent metallic marker in the breast to mark the area of biopsy. I have had adequate time to ask questions and all have been answered to my satisfaction. ADDITIONAL INSTRUCTIONS/PREP: STOP taking aspirin, BC powders, any aspirin or ibuprofen containing product; any food with curry powder, vitamin E, herbal supplements (garlic, ginger root, ginko biloba, fever few) one week prior to surgery. You may take Tylenol for mild pain or discomfort. We advise that you wear a two piece outfit and a good support ("sport") bra. Do not wear jewelry, underarm deodorant, powder or perfume. You may only eat a light meal prior to procedure. Do not take any diuretic (water) pills on the day of the biopsy. We will file your insurance for you if you have provided us with the necessary information. You are responsible for payment on your account. For most insurance plans, we will call for an approval number and file the insurance for the procedure. However, it is your responsibility to understand the coverage and benefits provided by your insurance package. Please call your company or representative with any questions regarding services covered, second opinions, pre-certification and patient responsibilities. SIGNED: _____________________________ DATE: ___________ WITNESS: ____________________________ DATE: ___________ If you have any questions, please call our office at (919) 782-8200. |