PATIENT CONSENT
You will be seen in a private examination room where you will be attended to by a State Licensed Physician, Nurse practitioner, or Physician’s Assistant who will examine you, check your general medical condition, ask about any medications you are presently taking, and discuss with you the specific problem for which you have come to the medical clinic.
The provider may then perform some diagnostic tests. The provider may apply a test dose of medication designed for your specific problem to the spongy tissue of the penis using an auto-applicator. The test dose of medication contains a combination of commonly used vasodilators including Papaverine, Phentolamine, Prostaglandin E1, and Lidocaine. This medication will dilate (open) the arteries so that the active blood flow (as when you are sexually excited) through the penis can be measured. A partial or full erection lasting 40-60 minutes usually results from this application. Sometimes, the erection in the clinic or at home can last longer than desired. Should this possibility occur, you will be advised on what
procedures to follow. These recommended procedures include taking oral Sudafed and/or an injection of Phenylephrine. Side effects include raised blood pressure and/or headache, nausea, vomiting, lightheadedness, and in extremely rare cases, stroke. Rarely, this application may produce a full erection lasting longer than two hours. Such prolonged erection is unusual and only occurs in those who are overly sensitive to the combination used. Long term and/or frequent use of this medication can cause penile scarring or a plaque buildup from the micro-injection. All these tests are required for treating providers to properly and effectively diagnose and treat your complaint. The provider may then prescribe a unique treatment plan designed to treat the cause of your Erectile Dysfunction if the provider believes it appropriate for your particular condition.
By initialing where indicated, I am acknowledging that I am not presently suffering from any of the above conditions. I further acknowledge that I have not used marijuana, or recreational drugs such as cocaine, heroin, or ecstasy within the last 36 hours. I further acknowledge that I have not used Viagra, Levitra, Cialis or any similar oral erectile medications within the last 36 hours. I agree to stay at the Regenerate Men’s Health Medical Clinic for as long as I have a partial or full erection on this visit and any further visits. Leaving before the erection has subsided (gone away) can increase the risk of a priapism (erection lasting longer than 4 hours) and may cause damage to the penis. X
*I understand that Regenerate Men’s Health Medical Clinic guarantees that in the event I fail to achieve an erection during the initial office visit, there will be no charge for the office visit. However, in the event that I complete the office visit having achieved an erection, the cost of the office visit, and/or other services or products, shall be non-refundable and the no-cost GUARANTEE shall terminate at the time the office visit has ended.