lifecareforwomen.com - Cellavate Consent form

Name*

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Date of Birth*

Date

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Absolute Contraindications (We cannot perform service If the answer is YES to any of the conditions below)

Relative Contraindications (That may be a concern with a possibility not to perform service if the answer is YES to the conditions below) Dr. Linda Sodoma will need to approve before the procedure

Consistent use of NSAlDs within 48 hours of procedureSystemic use of corticosteroids within 2 weeksTobacco useRecent fever or illnessCancer- especially hematopoietic or of boneChronic Liver PathologyHypofibrinogenemia

Cancellation Policy

Upon scheduling, you'll be asked to provide a credit card number to guarantee your treatment,
Your credit card information will be securely stored in your history file.
To avoid cancellation fees, please cancel or reschedule at least 24 hours before your appointment.
If you cancel with less than 24 hours' notice, your credit card on file will be charged the cancellation fee of $50.
No-shows will be charged 50% of the service fee.
Monday appointments must be canceled or rescheduled by Friday.
Appointment Reminders:
We'll send you a text message reminder before your scheduled service.
It's your responsibility to manage your appointment even if the reminder system fails.
We appreciate your understanding and cooperation. Thank you for choosing Linda I. Sodoma, DO,
PLC for your service.

Policy

POSSIBLE ADVERSE EFFECTS OF CELLEVATE TREATMENT

There is a risk of urinary retention, although small. A catheter will be placed into the bladder during the procedure and will be removed at the conclusion. It may be necessary to replace the catheter if urinary retention develops.
Urinary tract infection is another risk to this procedure and antibiotics will be given according to your Allergy profile to prevent this from happening.
Other risks may include allergy to lidocaine products. These are sh01t acting local anesthetics and should an allergy occur, it is usually of short duration.
Some patients may experience fainting as a result of blood withdrawal (rare). A bruise at the venipuncture site may be visible for 2-3 days.

PRE- PROCEDURE INSTRUCTIONS

Medication to Hold 2 days prior to procedure:
Aleve, Motrin, Ibuprofen
Warfarin,Xarelto, Eliquis, Plavix
Asprin or Baby Asprin

CELLAVATE CONSENT FORM

Business Policies