Stale of Callfornla-Heallh and Human SeNlces Agency Californ ia Depanmenl of PUtJllc Health

STERILIZATION CONSENT FORM (NON-FEDERALLY FUNDED) NOTICE YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF

ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS

CONSENT TO STERILIZATION STATEMENT OF PERSON OBTAINING CONSENT

Q I have asked for and received information about sterilization from

GeberT Eamiddot YU$CACYll ron (Doclo r Climc)

When I first asked for the information I was told that the decision to be sterilized is completely up to me I was told that I could decide not to be sterilized If I decide not to be sterilized my decision will not affect my righl to future care or Ireatment I understand that I ca n change my mind at any time

I UNDERSTAND THAT THE STERILIZA TtON MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT BEAR CHILDREN OR FATHER CHILDREN

I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a chitd in the future I have rejecled these alternatives and chosen to be sterilized

I understand that I will undergo an operation known as a

blOte ra vasecWOJj The discomforts risks and benefits associated with the operation have

been explained to me All my questions have been answered to my satisfaction

I understand that the operation will not be done until at least 30 days after I sign this form except in specific instances that have been fully explained to me

I wish to waive the 30middotday waiting period to ~ days (not less than 72 hours)

I am at least 18 years of age OR

I am under 18 ANO

I have entered into a valid marriage OR

I am on active duty wilh the US armed services OR

I have received a declaration or emancipation pursuant to Section 64 of the Civil Code OR

I am over 15 years old live apart from my parents or guardians and manage my own financial affairs

I was born on -----c------r=----==--shy(Month) (Day) (Year)

I hereby consent

Before ____ _____-_________ Signed the (Name of Individual)

consent form I explained to himher the nature of the sterilization operation

0 c - the fact that it is intended to be a final and irreversible procedure an the discomforts risks and benefits associated with it

I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary I explained that sterilization is different because it is permanent

I informed the individual to be sterilized that hisher consent can be withdrawn at any time and that heshe will not lose any health services or any benefits provided by federal funds

To the best of my knowledge and belief the individual to be sterilized is at least 18 years old or meets the necessary age requirements under applicable regulations and appears mentally competent HeShe knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure

I certify that I explained orally to the person to be sterilized the requirements for informed consent as set forth on this form and in applicable regulations

2_L---=---=-(S~ig e_o_ _ _ _ _ Ia-in nt---fn~alur_ f p erso Db_ ing~ccc07nse- ) p-_~~~l Vni1 02-( C-T ~aCllit1 ~

~~jcO) IWmiddot ~ tgt O~ ~ tcs j (lA- (A ass a o~J 7

PHYSICIANS STATEMENT - -V Shortly before I performed a sterilization operation upon

____~----~~--cc~----cc----on----~--~-------------(Name of indiVidual 10 be sfenlized) (Date of stenlzafon operatIOn)

I explained to himher the nature of the sterilization operation _____

0 ate CC vase c1C~ (Specify type of operation)

the fact that it is intended to be a final and irreversible procedure and the discomforts risks and benefits associated with it

I counseled the individual to be sterilized that alternative methods of birth cont rol are available which are temporary I explained that sterilization is different because it is permanent

I informed the individual to be sterilized that hisher consent can be Withdrawn at any time and that heshe Will not lose any health services or

of my own free Will to undergo an operallon Intended to stenllze me to be VV(t) benefits provided by federal funds

performed by~()t2e~ fi r u caC en I~ I W To the best of my knowledge and belief the indiVidual 10 be sterilized IS

0-ib Vl ifCtor) 10 -~ 1~-I at least 18 years old or meets the necessary age requirements under by a method called ~1L lIL SLl~~L bullV applicable regulations and appears mentally competent HeShe knowingly

I am not In labor and It has been at least 24 hours since I gave birth or had an abortion I am not seeking to obtain or obtaining an abortion at this time

I am not under the influence of alcohol or other substances that affect my state of awareness

I understand that I may have a witness of my choice present during the time my consent is obtained

My consent expires 180 days from Ihe date of my signalure below I have received a copy of Ihis form

( Signature) (Date [MonthfDaylYearj)

INTERPRETERS STATEMENT

If an interpreter IS provided to assist the individual to be sterilized I have translated the information and adVice presented orally to the

individual to be sterilized by the person obtaining this consent I have also

read himher the consent form in language and explained its contents to himher To the best of my knowledge and belief heshe understood this explanation

(Interpreter) (Dale [MonthfDaylYearj)

PM 284 (ENGSP) (707)

and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure

(Instructions for use of alternative final paragraphs Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery or patient waiver where the sterilization is performed less than 30 days after the date of the individuals Signature on the consent form In those cases the second paragraph below must be used Cross oul the paragraph which is not used)

1 AI least 30 days have passed between Ihe dale of the individuals signature on this consent form and the date the sterilization was performed

2 I certify thai this sterilization was performed less than 30 days bul more than 72 hours after the date of the individuals signature on Ihis consent form because of the following circumstances (check applicable box and fill in information requested)

a Premature delivery Individuals expected date of delivery middot

b Emergency abdominal surgery (describ-e- ci-rc-u-m-s-ta- n- c-e-s-)--- shy

Date individual intended to be sterilized __________ c Patient waived the 30middotday waiting period to _______ days

(Not less than 72 hours )

(Physician) (Date)

Page 1 of 2

Financial Responsibility Effective March 201 1

Date ________

Dear __________________

Thank you for selecting Pacific Coast Urology and Dr Robert Pugach for your care Please review this letter as it has important information about your upcoming procedure and financial responsibility Your care and well-being is our paramount concern If you have any questions please call our office so we can assist you

Your procedure is scheduled for at ampm Please read the pre-op information and follow the instructions carefully

To avoid cancellation of your procedure all payments co-payments or deductibles must be paid in full and received in our office at least one week before the above date We accept Visa MasterCard and Discover personal checks or cash You can make that payment in person with the above credit cards over the phone or by mailing a check to our office

If you have applicable insurance you will be notified in the next several days of the portion for which you are responsible

Please sign below to acknowledge your receipt of this letter and your understanding of it

Patient Signature Date

Pacific Coast Urology Medical Center 3801 Katella Ave Suite 110 Los Alamitos CA 90720

Ph 562594-0860

l II 1

UR(l LOGY MI-cbJi Cur

A Notice For Our Patients About Charges For Missed Appointments or Missed Procedures

UPDATED 08062012

You have now scheduled or plan to schedule an in-office vasectomy procedure

If you cannot keep your scheduled appointment you must notify our office no less than 48 business hours in advance Our business hours are Monday - Friday 800 am to 3 30 pm Ph 562-594-0860

If you do not change or cancel your appointment within this time period or do not show up the following charge will apply

Vasectomy $20000

Please note that these charges are not covered by insurance plans and will need to be paid to our office before we can reschedule your procedure

If a procedure is cancelled twice a new office visit will be required to discuss your procedure with Dr Pugach before you can schedule a third time

I have read the above infonnation and any questions that I had have been answered to my satisfaction I agree to pay the charges as outlined above

Print Patient Name

Patient Signature Date

Witness Date

I I [ ( I J

UR LOGY MiliM1 Ccuu

VASECTOMY INSTRUCTIONS

BEFORE YOUR VASECTOMY

1 Buy a LARGE scrotal supporter (jock strap) You can get one at a sporting goods store of places like Target or Walmart

2 Shave the front of your scrotum fr om the bottom to the base of the penis on the morning of your procedure Avoid using an electric razor or mentholshycontaining shaving creams

3 After shaving wash the shaved area well to remove any loose hair

4 Wear the scrotal supporter when you come to the office for your procedure You can wear it by itself or inside or outside your underwear

AFTER YOUR VASECTOMY

1 First 24 hours Go home and take it easy Horizontal is good lying on your back on a couch or in bed will help to minimize swelling - its the key to a faster recovery B a couch potato

2 On the day after your no needleno scalpel vasectomy remove the scrotal supporter and dressings and take a shower After that put the supporter back on and wear it for about a week - either inside or outsi de of your underwear It helps to prevent a heavy or tugging sensation

3 After your shower try to apply ice for about 30 minutes every 1-2 hours for the rest of the day You can put ice cubes in a ziplock bag or use frozen peas or frozen corn

4 For 3 - 5 days after your No ScalpelNo Needle vasectomy its a good idea to avoid strenuous activities and lifting heavy objects If you work out and do a lot of abdominal straining you can resume your workouts in 7 days Sex can be resumed 48 hours after your procedure

5 Dont apply ointments creams or powder to the skin separation site

6 Discomfort or pain can usually be relieved by Extra-Strength Tylenol (1-2 every 6 hours) or anti-inflammatory products like Ibuprofen (generic for Motrin Adv il etc) at a dose of 400-600 mg every 8 hours Be sure to follow manufacturers warnings and cautions for all medicines that you take

7 Slight oozing tenderness and swelling may occur and usually subsides within 48-72 hours

8 Please call if you develop a fever significant swelling o f the scrotum persistent or a discharge from the vasectomy site

9 REMEMBER - YOU CANNOT BE CONSIDERED STERILE UNTIL AT LEAST 2 SEMEN TESTS HAVE BEEN CHECKED AFTER YOUR PROCEDURE THE FIRST SPECIMEN IS COLLECTED 6 WEEKS AFTER SURGERY AND THE SECOND ABOUT 4 WEEKS LATER BE CAREFUL TO PREVENT PREGNANCY YOU AND YOUR PARTNER MUST USE AN APPROPRIATE FORM OF BIRTH CONTROL UNTIL YOUR

SPERM COUNT IS 0 ON TWO SEPARATE TESTS

10 Dr Pugach checks all semen samples himself You dont need an appointment for this - just call us the day BEFORE you plan to bring in a specimen to be sure Dr Pugach will be here to check it After you drop it off call us a couple of hours later for the results Its as simple as that

PLEASE NOTE THERE IS A $25 CHARGE FOR A SCROTAL SUPPORTER IF YOU DONT PROVIDE ONE

fCfIC COAST UR()LOGY

M~di(a1 CUll

Supplemental Vasectomy Consent

By signing this form you acknowledge that you have received information from Pacific Coast Urology Medical Center Inc about a bilateral vasectomy procedure Some of the specific issues discussed were

bull The routine complications from a surgical procedure bull The procedure should be considered permanent and irreversible bull There is a small possibility of an increase in the development of prostate cancer

following the procedure There is conflicting information about this bull Tiny stainless steel clips will be used to help seal the ends of each vas deferens

- these will remain in you after the procedure bull You are not sterile immediately after the procedure It will take a minimum of

10 weeks for that to occur Until you have been notified that 2 semen samples taken one month apart show 0 (zero) sperm you should continue to use some form of contraception if you do not want to achieve a pregnancy

bull You must bring in at least 2 samples of semen to determine if the procedure was successful The first will be approximately 6 weeks after the procedure and the second will be 1 month after that If any specimen shows any sperm samples will continue to be checked until 2 of them taken one month apart show 0 (zero) sperm If you do not bring in semen samples as described above there is no guarantee that the procedure was successful Dr Pugach looks at each specimen personally so you must call our office the day before you want to bring in your specimen to be sure he will be in the office the next day

bull Even if you are tola that you no longer need to use contraception there can be a spontaneous re-growth of the vas deferens (the tubes that were cut) and they could join together in the future The likelihood of this happening is approximately 1 in 10000 patients

I understand the contents of this page and the counseling provided by Pacific Coast Urology Medical Center Inc I have had sufficient opportunity to ask questions and they have been answered to my satisfaction so that I understand the procedure called a bilateral vasectomy I also understand that the decision to have a vasectomy is entirely voluntary

Patient Date

Witness Date

----------------

LCI IC C()gtI

URULOGY MItiiltdC(7fur

Vasectomy Operative Report

Patient ~~__~~ ____________ Date

Pre-procedure medication o Ibuprofen 600 mg o Keflex 500 mg

Procedure o No-Scalpel Vasectomy o Scalpel Vasectomy

Prep 0 Betadine paint x 3 o

Anesthetic o No-Needle __ shots ofO5 Marcaine to skin and vas on each side using Madajet XL o Needle cc of 05 Marcaine to scrotal skin and vas on each side

Technique Each vas was grasped using a 3 finger technique

o The skin in the midline was separated with the special no-scalpel vas device The left vas deferens was then grasped with the special no-scalpel vas clamp and pulled out of the incision

o The skin was incised in the midline with a II blade The left vas deferens was then grasped with an Allis clamp and was pulled out of the incision

All layers were carefully stripped off The vas was clipped on each side and divided The lumen of each cut end was cauterized Any small bleeding vessels were cauterized as well The vas ends were placed back into the scrotum An identical procedure was performed on the contralateral side A 4-0 chromic suture waswas not used to close the skin opening Fluff dressings and a scrotal supporter were applied

Post-procedure BP ___ _

Robert G Pugach MD

l II 1

UR(l LOGY MI-cbJi Cur

A Notice For Our Patients About Charges For Missed Appointments or Missed Procedures

UPDATED 08062012

You have now scheduled or plan to schedule an in-office vasectomy procedure

If you cannot keep your scheduled appointment you must notify our office no less than 48 business hours in advance Our business hours are Monday - Friday 800 am to 3 30 pm Ph 562-594-0860

If you do not change or cancel your appointment within this time period or do not show up the following charge will apply

Vasectomy $20000

Please note that these charges are not covered by insurance plans and will need to be paid to our office before we can reschedule your procedure

If a procedure is cancelled twice a new office visit will be required to discuss your procedure with Dr Pugach before you can schedule a third time

I have read the above infonnation and any questions that I had have been answered to my satisfaction I agree to pay the charges as outlined above

Print Patient Name

Patient Signature Date

Witness Date

I I [ ( I J

UR LOGY MiliM1 Ccuu

VASECTOMY INSTRUCTIONS

BEFORE YOUR VASECTOMY

1 Buy a LARGE scrotal supporter (jock strap) You can get one at a sporting goods store of places like Target or Walmart

2 Shave the front of your scrotum fr om the bottom to the base of the penis on the morning of your procedure Avoid using an electric razor or mentholshycontaining shaving creams

3 After shaving wash the shaved area well to remove any loose hair

4 Wear the scrotal supporter when you come to the office for your procedure You can wear it by itself or inside or outside your underwear

AFTER YOUR VASECTOMY

1 First 24 hours Go home and take it easy Horizontal is good lying on your back on a couch or in bed will help to minimize swelling - its the key to a faster recovery B a couch potato

2 On the day after your no needleno scalpel vasectomy remove the scrotal supporter and dressings and take a shower After that put the supporter back on and wear it for about a week - either inside or outsi de of your underwear It helps to prevent a heavy or tugging sensation

3 After your shower try to apply ice for about 30 minutes every 1-2 hours for the rest of the day You can put ice cubes in a ziplock bag or use frozen peas or frozen corn

4 For 3 - 5 days after your No ScalpelNo Needle vasectomy its a good idea to avoid strenuous activities and lifting heavy objects If you work out and do a lot of abdominal straining you can resume your workouts in 7 days Sex can be resumed 48 hours after your procedure

5 Dont apply ointments creams or powder to the skin separation site

6 Discomfort or pain can usually be relieved by Extra-Strength Tylenol (1-2 every 6 hours) or anti-inflammatory products like Ibuprofen (generic for Motrin Adv il etc) at a dose of 400-600 mg every 8 hours Be sure to follow manufacturers warnings and cautions for all medicines that you take

7 Slight oozing tenderness and swelling may occur and usually subsides within 48-72 hours

8 Please call if you develop a fever significant swelling o f the scrotum persistent or a discharge from the vasectomy site

9 REMEMBER - YOU CANNOT BE CONSIDERED STERILE UNTIL AT LEAST 2 SEMEN TESTS HAVE BEEN CHECKED AFTER YOUR PROCEDURE THE FIRST SPECIMEN IS COLLECTED 6 WEEKS AFTER SURGERY AND THE SECOND ABOUT 4 WEEKS LATER BE CAREFUL TO PREVENT PREGNANCY YOU AND YOUR PARTNER MUST USE AN APPROPRIATE FORM OF BIRTH CONTROL UNTIL YOUR

SPERM COUNT IS 0 ON TWO SEPARATE TESTS

10 Dr Pugach checks all semen samples himself You dont need an appointment for this - just call us the day BEFORE you plan to bring in a specimen to be sure Dr Pugach will be here to check it After you drop it off call us a couple of hours later for the results Its as simple as that

PLEASE NOTE THERE IS A $25 CHARGE FOR A SCROTAL SUPPORTER IF YOU DONT PROVIDE ONE

fCfIC COAST UR()LOGY

M~di(a1 CUll

Supplemental Vasectomy Consent

By signing this form you acknowledge that you have received information from Pacific Coast Urology Medical Center Inc about a bilateral vasectomy procedure Some of the specific issues discussed were

bull The routine complications from a surgical procedure bull The procedure should be considered permanent and irreversible bull There is a small possibility of an increase in the development of prostate cancer

following the procedure There is conflicting information about this bull Tiny stainless steel clips will be used to help seal the ends of each vas deferens

- these will remain in you after the procedure bull You are not sterile immediately after the procedure It will take a minimum of

10 weeks for that to occur Until you have been notified that 2 semen samples taken one month apart show 0 (zero) sperm you should continue to use some form of contraception if you do not want to achieve a pregnancy

bull You must bring in at least 2 samples of semen to determine if the procedure was successful The first will be approximately 6 weeks after the procedure and the second will be 1 month after that If any specimen shows any sperm samples will continue to be checked until 2 of them taken one month apart show 0 (zero) sperm If you do not bring in semen samples as described above there is no guarantee that the procedure was successful Dr Pugach looks at each specimen personally so you must call our office the day before you want to bring in your specimen to be sure he will be in the office the next day

bull Even if you are tola that you no longer need to use contraception there can be a spontaneous re-growth of the vas deferens (the tubes that were cut) and they could join together in the future The likelihood of this happening is approximately 1 in 10000 patients

I understand the contents of this page and the counseling provided by Pacific Coast Urology Medical Center Inc I have had sufficient opportunity to ask questions and they have been answered to my satisfaction so that I understand the procedure called a bilateral vasectomy I also understand that the decision to have a vasectomy is entirely voluntary

Patient Date

Witness Date

----------------

LCI IC C()gtI

URULOGY MItiiltdC(7fur

Vasectomy Operative Report

Patient ~~__~~ ____________ Date

Pre-procedure medication o Ibuprofen 600 mg o Keflex 500 mg

Procedure o No-Scalpel Vasectomy o Scalpel Vasectomy

Prep 0 Betadine paint x 3 o

Anesthetic o No-Needle __ shots ofO5 Marcaine to skin and vas on each side using Madajet XL o Needle cc of 05 Marcaine to scrotal skin and vas on each side

Technique Each vas was grasped using a 3 finger technique

o The skin in the midline was separated with the special no-scalpel vas device The left vas deferens was then grasped with the special no-scalpel vas clamp and pulled out of the incision

o The skin was incised in the midline with a II blade The left vas deferens was then grasped with an Allis clamp and was pulled out of the incision

All layers were carefully stripped off The vas was clipped on each side and divided The lumen of each cut end was cauterized Any small bleeding vessels were cauterized as well The vas ends were placed back into the scrotum An identical procedure was performed on the contralateral side A 4-0 chromic suture waswas not used to close the skin opening Fluff dressings and a scrotal supporter were applied

Post-procedure BP ___ _

Robert G Pugach MD

I I [ ( I J

UR LOGY MiliM1 Ccuu

VASECTOMY INSTRUCTIONS

BEFORE YOUR VASECTOMY

1 Buy a LARGE scrotal supporter (jock strap) You can get one at a sporting goods store of places like Target or Walmart

2 Shave the front of your scrotum fr om the bottom to the base of the penis on the morning of your procedure Avoid using an electric razor or mentholshycontaining shaving creams

3 After shaving wash the shaved area well to remove any loose hair

4 Wear the scrotal supporter when you come to the office for your procedure You can wear it by itself or inside or outside your underwear

AFTER YOUR VASECTOMY

1 First 24 hours Go home and take it easy Horizontal is good lying on your back on a couch or in bed will help to minimize swelling - its the key to a faster recovery B a couch potato

2 On the day after your no needleno scalpel vasectomy remove the scrotal supporter and dressings and take a shower After that put the supporter back on and wear it for about a week - either inside or outsi de of your underwear It helps to prevent a heavy or tugging sensation

3 After your shower try to apply ice for about 30 minutes every 1-2 hours for the rest of the day You can put ice cubes in a ziplock bag or use frozen peas or frozen corn

4 For 3 - 5 days after your No ScalpelNo Needle vasectomy its a good idea to avoid strenuous activities and lifting heavy objects If you work out and do a lot of abdominal straining you can resume your workouts in 7 days Sex can be resumed 48 hours after your procedure

5 Dont apply ointments creams or powder to the skin separation site

6 Discomfort or pain can usually be relieved by Extra-Strength Tylenol (1-2 every 6 hours) or anti-inflammatory products like Ibuprofen (generic for Motrin Adv il etc) at a dose of 400-600 mg every 8 hours Be sure to follow manufacturers warnings and cautions for all medicines that you take

7 Slight oozing tenderness and swelling may occur and usually subsides within 48-72 hours

8 Please call if you develop a fever significant swelling o f the scrotum persistent or a discharge from the vasectomy site

9 REMEMBER - YOU CANNOT BE CONSIDERED STERILE UNTIL AT LEAST 2 SEMEN TESTS HAVE BEEN CHECKED AFTER YOUR PROCEDURE THE FIRST SPECIMEN IS COLLECTED 6 WEEKS AFTER SURGERY AND THE SECOND ABOUT 4 WEEKS LATER BE CAREFUL TO PREVENT PREGNANCY YOU AND YOUR PARTNER MUST USE AN APPROPRIATE FORM OF BIRTH CONTROL UNTIL YOUR

SPERM COUNT IS 0 ON TWO SEPARATE TESTS

10 Dr Pugach checks all semen samples himself You dont need an appointment for this - just call us the day BEFORE you plan to bring in a specimen to be sure Dr Pugach will be here to check it After you drop it off call us a couple of hours later for the results Its as simple as that

PLEASE NOTE THERE IS A $25 CHARGE FOR A SCROTAL SUPPORTER IF YOU DONT PROVIDE ONE

fCfIC COAST UR()LOGY

M~di(a1 CUll

Supplemental Vasectomy Consent

By signing this form you acknowledge that you have received information from Pacific Coast Urology Medical Center Inc about a bilateral vasectomy procedure Some of the specific issues discussed were

bull The routine complications from a surgical procedure bull The procedure should be considered permanent and irreversible bull There is a small possibility of an increase in the development of prostate cancer

following the procedure There is conflicting information about this bull Tiny stainless steel clips will be used to help seal the ends of each vas deferens

- these will remain in you after the procedure bull You are not sterile immediately after the procedure It will take a minimum of

10 weeks for that to occur Until you have been notified that 2 semen samples taken one month apart show 0 (zero) sperm you should continue to use some form of contraception if you do not want to achieve a pregnancy

bull You must bring in at least 2 samples of semen to determine if the procedure was successful The first will be approximately 6 weeks after the procedure and the second will be 1 month after that If any specimen shows any sperm samples will continue to be checked until 2 of them taken one month apart show 0 (zero) sperm If you do not bring in semen samples as described above there is no guarantee that the procedure was successful Dr Pugach looks at each specimen personally so you must call our office the day before you want to bring in your specimen to be sure he will be in the office the next day

bull Even if you are tola that you no longer need to use contraception there can be a spontaneous re-growth of the vas deferens (the tubes that were cut) and they could join together in the future The likelihood of this happening is approximately 1 in 10000 patients

I understand the contents of this page and the counseling provided by Pacific Coast Urology Medical Center Inc I have had sufficient opportunity to ask questions and they have been answered to my satisfaction so that I understand the procedure called a bilateral vasectomy I also understand that the decision to have a vasectomy is entirely voluntary

Patient Date

Witness Date

----------------

LCI IC C()gtI

URULOGY MItiiltdC(7fur

Vasectomy Operative Report

Patient ~~__~~ ____________ Date

Pre-procedure medication o Ibuprofen 600 mg o Keflex 500 mg

Procedure o No-Scalpel Vasectomy o Scalpel Vasectomy

Prep 0 Betadine paint x 3 o

Anesthetic o No-Needle __ shots ofO5 Marcaine to skin and vas on each side using Madajet XL o Needle cc of 05 Marcaine to scrotal skin and vas on each side

Technique Each vas was grasped using a 3 finger technique

o The skin in the midline was separated with the special no-scalpel vas device The left vas deferens was then grasped with the special no-scalpel vas clamp and pulled out of the incision

o The skin was incised in the midline with a II blade The left vas deferens was then grasped with an Allis clamp and was pulled out of the incision

All layers were carefully stripped off The vas was clipped on each side and divided The lumen of each cut end was cauterized Any small bleeding vessels were cauterized as well The vas ends were placed back into the scrotum An identical procedure was performed on the contralateral side A 4-0 chromic suture waswas not used to close the skin opening Fluff dressings and a scrotal supporter were applied

Post-procedure BP ___ _

Robert G Pugach MD

SPERM COUNT IS 0 ON TWO SEPARATE TESTS

10 Dr Pugach checks all semen samples himself You dont need an appointment for this - just call us the day BEFORE you plan to bring in a specimen to be sure Dr Pugach will be here to check it After you drop it off call us a couple of hours later for the results Its as simple as that

PLEASE NOTE THERE IS A $25 CHARGE FOR A SCROTAL SUPPORTER IF YOU DONT PROVIDE ONE

fCfIC COAST UR()LOGY

M~di(a1 CUll

Supplemental Vasectomy Consent

By signing this form you acknowledge that you have received information from Pacific Coast Urology Medical Center Inc about a bilateral vasectomy procedure Some of the specific issues discussed were

bull The routine complications from a surgical procedure bull The procedure should be considered permanent and irreversible bull There is a small possibility of an increase in the development of prostate cancer

following the procedure There is conflicting information about this bull Tiny stainless steel clips will be used to help seal the ends of each vas deferens

- these will remain in you after the procedure bull You are not sterile immediately after the procedure It will take a minimum of

10 weeks for that to occur Until you have been notified that 2 semen samples taken one month apart show 0 (zero) sperm you should continue to use some form of contraception if you do not want to achieve a pregnancy

bull You must bring in at least 2 samples of semen to determine if the procedure was successful The first will be approximately 6 weeks after the procedure and the second will be 1 month after that If any specimen shows any sperm samples will continue to be checked until 2 of them taken one month apart show 0 (zero) sperm If you do not bring in semen samples as described above there is no guarantee that the procedure was successful Dr Pugach looks at each specimen personally so you must call our office the day before you want to bring in your specimen to be sure he will be in the office the next day

bull Even if you are tola that you no longer need to use contraception there can be a spontaneous re-growth of the vas deferens (the tubes that were cut) and they could join together in the future The likelihood of this happening is approximately 1 in 10000 patients

I understand the contents of this page and the counseling provided by Pacific Coast Urology Medical Center Inc I have had sufficient opportunity to ask questions and they have been answered to my satisfaction so that I understand the procedure called a bilateral vasectomy I also understand that the decision to have a vasectomy is entirely voluntary

Patient Date

Witness Date

----------------

LCI IC C()gtI

URULOGY MItiiltdC(7fur

Vasectomy Operative Report

Patient ~~__~~ ____________ Date

Pre-procedure medication o Ibuprofen 600 mg o Keflex 500 mg

Procedure o No-Scalpel Vasectomy o Scalpel Vasectomy

Prep 0 Betadine paint x 3 o

Anesthetic o No-Needle __ shots ofO5 Marcaine to skin and vas on each side using Madajet XL o Needle cc of 05 Marcaine to scrotal skin and vas on each side

Technique Each vas was grasped using a 3 finger technique

o The skin in the midline was separated with the special no-scalpel vas device The left vas deferens was then grasped with the special no-scalpel vas clamp and pulled out of the incision

o The skin was incised in the midline with a II blade The left vas deferens was then grasped with an Allis clamp and was pulled out of the incision

All layers were carefully stripped off The vas was clipped on each side and divided The lumen of each cut end was cauterized Any small bleeding vessels were cauterized as well The vas ends were placed back into the scrotum An identical procedure was performed on the contralateral side A 4-0 chromic suture waswas not used to close the skin opening Fluff dressings and a scrotal supporter were applied

Post-procedure BP ___ _

Robert G Pugach MD

fCfIC COAST UR()LOGY

M~di(a1 CUll

Supplemental Vasectomy Consent

By signing this form you acknowledge that you have received information from Pacific Coast Urology Medical Center Inc about a bilateral vasectomy procedure Some of the specific issues discussed were

bull The routine complications from a surgical procedure bull The procedure should be considered permanent and irreversible bull There is a small possibility of an increase in the development of prostate cancer

following the procedure There is conflicting information about this bull Tiny stainless steel clips will be used to help seal the ends of each vas deferens

- these will remain in you after the procedure bull You are not sterile immediately after the procedure It will take a minimum of

10 weeks for that to occur Until you have been notified that 2 semen samples taken one month apart show 0 (zero) sperm you should continue to use some form of contraception if you do not want to achieve a pregnancy

bull You must bring in at least 2 samples of semen to determine if the procedure was successful The first will be approximately 6 weeks after the procedure and the second will be 1 month after that If any specimen shows any sperm samples will continue to be checked until 2 of them taken one month apart show 0 (zero) sperm If you do not bring in semen samples as described above there is no guarantee that the procedure was successful Dr Pugach looks at each specimen personally so you must call our office the day before you want to bring in your specimen to be sure he will be in the office the next day

bull Even if you are tola that you no longer need to use contraception there can be a spontaneous re-growth of the vas deferens (the tubes that were cut) and they could join together in the future The likelihood of this happening is approximately 1 in 10000 patients

I understand the contents of this page and the counseling provided by Pacific Coast Urology Medical Center Inc I have had sufficient opportunity to ask questions and they have been answered to my satisfaction so that I understand the procedure called a bilateral vasectomy I also understand that the decision to have a vasectomy is entirely voluntary

Patient Date

Witness Date

----------------

LCI IC C()gtI

URULOGY MItiiltdC(7fur

Vasectomy Operative Report

Patient ~~__~~ ____________ Date

Pre-procedure medication o Ibuprofen 600 mg o Keflex 500 mg

Procedure o No-Scalpel Vasectomy o Scalpel Vasectomy

Prep 0 Betadine paint x 3 o

Anesthetic o No-Needle __ shots ofO5 Marcaine to skin and vas on each side using Madajet XL o Needle cc of 05 Marcaine to scrotal skin and vas on each side

Technique Each vas was grasped using a 3 finger technique

o The skin in the midline was separated with the special no-scalpel vas device The left vas deferens was then grasped with the special no-scalpel vas clamp and pulled out of the incision

o The skin was incised in the midline with a II blade The left vas deferens was then grasped with an Allis clamp and was pulled out of the incision

All layers were carefully stripped off The vas was clipped on each side and divided The lumen of each cut end was cauterized Any small bleeding vessels were cauterized as well The vas ends were placed back into the scrotum An identical procedure was performed on the contralateral side A 4-0 chromic suture waswas not used to close the skin opening Fluff dressings and a scrotal supporter were applied

Post-procedure BP ___ _

Robert G Pugach MD

----------------

LCI IC C()gtI

URULOGY MItiiltdC(7fur

Vasectomy Operative Report

Patient ~~__~~ ____________ Date

Pre-procedure medication o Ibuprofen 600 mg o Keflex 500 mg

Procedure o No-Scalpel Vasectomy o Scalpel Vasectomy

Prep 0 Betadine paint x 3 o

Anesthetic o No-Needle __ shots ofO5 Marcaine to skin and vas on each side using Madajet XL o Needle cc of 05 Marcaine to scrotal skin and vas on each side

Technique Each vas was grasped using a 3 finger technique

o The skin in the midline was separated with the special no-scalpel vas device The left vas deferens was then grasped with the special no-scalpel vas clamp and pulled out of the incision

o The skin was incised in the midline with a II blade The left vas deferens was then grasped with an Allis clamp and was pulled out of the incision

All layers were carefully stripped off The vas was clipped on each side and divided The lumen of each cut end was cauterized Any small bleeding vessels were cauterized as well The vas ends were placed back into the scrotum An identical procedure was performed on the contralateral side A 4-0 chromic suture waswas not used to close the skin opening Fluff dressings and a scrotal supporter were applied

Post-procedure BP ___ _

Robert G Pugach MD