Maximum Perofmance - Advanced Male Medical Center最大perofmance先进男性医学中心

Advan__d __leMedical __nterINFORMED PATIENT CONSENTDear Patient,A doctor who __y perform some diagno

Advan__d__le Medical__nter INFORMEDPATIENTCONSENT DearPatient, Echo Adoctorwho__yperformsomediagnostictestswillattendtoyoushortly.Thefirsttestiscalled Doppler Ultrasound.Itmeasuresthebloodflowthroughthepenis.Yourdoctorwillfirstlocatethe c__ernosalarteryinthepenisandmeasure“passive”bloodflow(whenyouarenot___uallyexcited). Thedoctorthenusuallyappliesadoseofmedicationtothespongytissueofthepenisusingan auto-applicator.Thisapplicationispainless.Themedicationcontainsacombinationofcommonlyused vasodilatorsincludingPap__erine,Phentolamine,AtropineandProstaglandinE1.Itwilldilatethe capillariessothatthe“active”bloodflow(aswhenyouare___uallyexcited)throughthepeniscanbe measured.Apartialorfullerectionlasting40-60minutesusuallyresultsfromthisapplication. Rarely,thisapplication__yprodu__afullerectionlastinglongerthantwohours.Suchprolonged erectionisunusualandonlyoccursinthosewhoareoverlysensitivetothecombinationused.Should therebeapossibilityofthisoccurring;youwillbeadvisedonwhatpro__duresshouldbefollowed. Otherrareeffectsofthispro__dureincludelightheadednessmostlyduetonervousness. I,____________________________________,fullyunderstandthenatureoftheabovetestsandthe possiblesideeffects.Iconsenttoamedicalconsultationfeeof$ 2 9 9 . 0 0 *uponcompletionofthe $199.00 visit,andunderstandthatthechargespaidforanyothermedicationwhichI__yelecttopurchaseare final.IconsenttotreatmentbymytreatingdoctorshouldIexperien__anyinopportunesymptoms.I alsounderstandthattheseservi__sareconsideredelectivetreatmentandarenotcoveredbyMedicare, andthatanymedicationsorderedbymearebylawnon-refundable. Ih__ebeeninformedthatIh__etherighttochoosethephar__cyforfillinganyprescriptionwritten. IherebyauthorizeAdvan__d__leMedical__nterto__intainthemedicalrecordsandmedicalchartsfor medicalservi__sprovidedtome,andIh__ereadandunderstandAdvan__d__leMedical__nterHIPAA StatementandNoti__ofPrivacyPracti__s. Signedthis_______dayof__________,2009 Patient’sSignature:_________________________________________ DoctorsSignature:__________________________________________ *IunderstandthatAdvan__d__leMedical__nterguaranteesthatintheeventIfailtoachievean erectionduringtheinitialoffi__visit,therewillbenochargefortheoffi__visit.However,intheevent thatIcompletetheoffi__visith__ingachievedtheerection,thecostoftheoffi__visit,themedications, and/orotherservi__sorproducts,shallbenon-refundableandthenocostGUARANTEEshallterminate atthetimetheoffi__visithadended.