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Yung cYUNG C. CHEN, M.D. OF SAN MATEO SPINE CENTER, SPINE & MUSCULOSKELETAL MEDICINE, PHYSICAL MEDICINE & REHABILITATION
101 S. SAN MATEO DR. SUITE 301, SAN MATEO, CA 94401, TEL: 650-558-1802, FAX: 650-558-1806
STOP taking Aspirin, Aspiring-containing products, Anti-Inflammatories, or Blood-thinners for 7 days prior to the procedure. These may include, but are not limited to: Ibuprofen,
Advil, Motrin, Alieve, Naprosyn, Daypro, Relafen, Voltaren, Coumadin, Warfarin, Plavix, Heparin, etc. Call your pharmacist if you are in doubt of what your current medications may
contain. Before stopping any blood-thinners, make sure to get your prescribing doctor’s written clearance fax to our office, stating that you may be off your blood-thinners for the duration. If
you neglect to follow these instructions, you will be required to do a Bleeding Time Test on the day prior to your procedure. You may be required to do PT/PTT/INR Tests.
DO NOT STOP taking your heart, blood pressure, or lung medications. Bring your asthma inhalers with you.
If you are diabetic or hypoglycemic, your appointment should be scheduled before 10:00AM. Do not take your diabetes medications on the day of your appointment. However, do NOT
forget to bring them with you. You will be asked to take your medications after your procedure is performed. Inform Dr. Chen if you are taking antibiotics, had recent surgery, have an infection, experiencing chest pain, or getting a cold or flu.
You must begin fasting and not consume alcoholic beverages at 12 midnight the day of the procedure. Sips of water may be taken with medications.
Shower before procedure using any skin cleansers. If undergoing a cervical procedure, men should be clean-shaven from chin to neck.
Dress casually. Wear socks. Please wear undergarments. Do not wear any jewelry.
You MUST HAVE A DRIVER ALL THE TIME accompanying you on the day of the injection except during the actual procedure. A cab driver is not considered a companion. Please park in
the underground parking at Mills Square Hillsborough Plaza, entrance located on Ellsworth Street.
Please bring your most recent MRI, XRAY, and CT films to the appointment. This is your responsibility.
Please read and fill out the paperwork completely and bring it with you to your appointment.
WHAT TO EXPECT ON THE DAY OF THE PROCEDURE
Following check-in, you will be taken to a preparation room. Your designated driver may accompany you to this room. However, the driver will not be viewing the procedure. You will be asked to change, depending on the necessity and your procedure, to a pair of shorts and/or a half gown. You may choose to provide your own attire as appropriate. The staff member will then take your blood pressure and a brief history of your current region of concern. The staff member will mark the location that will be undergoing the procedure for You will have the opportunity to speak with Dr. Chen to review XRAY, MRI, CT, or other related lab results and voice any final concerns or questions before the procedure. The staff member will then escort you to the procedure room where you will be asked to lay flat on your stomach in most cases. The staff member will assist in the positioning and sterilization procedure before Dr. Chen performs the procedure. You will feel a cold spray as the region undergoing the procedure is locally anesthetized. Dr. Chen will guide the needle placement using live XRAY equipment. Dr. Chen will subsequently proceed with the procedure, which will be approximately 5 minutes in duration. Following the procedure, the staff member will assist in the cleansing and bandaging of the treated area. The staff member will escort you back to your preparation room, measure your blood pressure, and provide you with a light snack and beverage. You will be asked to stay and relax in the room with your designated driver, as Dr. Chen and the staff members wants to ensure your stability before discharge. A staff member will then review the post-procedure instructions with you and answer any questions or concerns you may have. You will be provided with a copy of the post-procedure instructions, an antibiotics prescription, and a follow-up appointment date in two weeks. We hope you will feel better soon! POST-PROCEDURE INSTRUCTIONS
Do not drive within the next 12 hours. Coordination may be impaired. Avoid twisting, bending, turning, pushing, pulling, lifting >5lbs, walking uphill, physical therapy, excessive exercise,
chiropractic work, swimming, massages, or bath tubs for one week even if you feel great! Shower is OK anytime. If you are diabetic, inform your attending physician. Steroids elevate blood sugar.
Cortisone or Steroid can have the following side effects: sweating, slight fever, flushing, palpitations, increased heart rate, insomnia, anxiety, mood swings, depression, hiccoughs,
headaches, generalized swelling, upset stomach, menstrual changes, frequent urination, or flu-like symptoms. If they occur, they usually only last for one week. If any of these side effects becomes significant or persists longer than one week, contact your physician. Icing the injection area 20 minutes at a time, 3 times a day, for 2 days, will reduce local soreness. Use an ice bag covered with a thin cloth.
Increased pain may be experienced 1-14 days after the injection. Improvement may be seen in 2-3 days but may not occur for 2-3 weeks.
Return to work: Usually, patients return to work 1-7 days following the injection. The doctor will determine this.
Resume ALL medications. Antibiotics prescribed are for your precautionary safety. Please contact San Mateo Spine Center for any further question(s).
Lumbar facet joint injection
Thoracic facet joint injection
Cervical facet joint injection
SI joint injection
Transforaminal lumbar epidural injection
Transforaminal thoracic epidural injection
Transforaminal cervical epidural injection
Lumbar RF/Cervical RF
Lumbar selective nerve root injection
Thoracic selective nerve root injection
Cervical selective nerve root injection
Left Knee/Right Knee
California state law guarantees that you have both the right and obligation to make decisions concerning your health care. Your physician can provide you with the necessary information and advice, but you must enter into the decision making process. This form has been designed to acknowledge your acceptance of treatment recommended by Dr. Chen. I have had the opportunity to discuss my condition with Dr. Chen and was given other alternative treatment options. Dr. Chen has informed me the alternatives to the proposed procedure above as well as the potential benefits, risks or side effects associated with these alternatives. I was given a description of this procedure. All potential benefits, risks, or side effects were explained to me. I have been informed about the goals of this procedure. I am aware that this procedure is palliative, and it is not curative. I understand that there is no 100% guarantee for pain relief with this procedure, and sometimes, it may make my pain worse. If I am a woman, I am certain that I am not pregnant now. I will take steps to be certain that I do not become pregnant over the period of time I am being treated. I understand that if I am pregnant now or become pregnant during the course of treatment, there is a risk that my unborn baby could be damaged by one or more of the medications used for treatment, sedation, or anesthesia. If during the course of treatment, I become uncertain whether or not I might be pregnant, I will immediately notify my treating physician and discontinue the treatment until I am again sure that I am not pregnant. Common reactions to the procedure: You may experience increased regional numbness, weakness, or dizziness for 1-4 hours after the injection. Fainting may occur, and we advise you not to operate a vehicle or perform activities requiring coordination for 12 hours after the procedure. Reactions to medications may include temporary allergic reaction and/or a decrease/increase blood pressure approximately 1% of the time. 20% of patients may have increased pain for 1-7 days after the procedure. 1% of patients may have a headache after the procedure. Treatment of the headache may necessitate additional procedures and/or hospitalization. Although serious complications are rare, they can occur. Possible serious complications include increase pain, headache, hip (bone) damage caused by steroids, temporary or permanent nerve impairment, infection, bleeding, infection, difficulty breathing, collapsed lung, partial or total paralysis, seizure, or death. CREDIT AGREEMENT
Although your insurance may pay for this service, your insurance frequently only pays a portion of the charges. Therefore, each patient or responsible party must understand these credit terms. Proceeds from your insurance will be promptly credited to your account. Any remaining balance must be paid within 30 days. Medicare Patient’s Release of Information: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize release of any information needed to act on this request. I request that payment of authorized benefits be made in my behalf. I understand that I am responsible for any remaining balance not covered by my insurance(s). Release of Information: I authorize the release of any medical information necessary to process this claim with my insurance carrier. I hereby certify that the information is true and correct. I understand that I am financially responsible for the unpaid balance of all accounts in the event that the authorization is insufficient to liquidate my account. In understand that the financial information herein supplied to me may be provided to a consumer credit bureau and/or to other health care providers involved in the performance of patient care. I understand that should by account be sent to collections or require litigation to liquidate, I will be responsible for any and all costs or fees incurred, including reasonable attorney fees. Assignment of Benefits: The undersigned assigns and hereby authorizes direct payment to the San Mateo Spine Center all insurance and plan benefits otherwise payable to or on behalf of the patient for services rendered. It is understood that I am financially responsible for charges not covered by this assignment. XRAY services: Vista Imaging Services, Inc. will be providing XRAY services during the procedure. You may see separate charges or fees on your insurance statement related to your procedure from Vista Imaging Services, Inc. Please call 858/622-0792 for any XRAY-related billing questions. Address: 5288 Eastgate Mall, San Diego, CA 92121
I have read and understand all of the above. By signing below, I agree to comply with all of the pre- and post-procedure requirements. Furthermore, I acknowledge that I have discuss with the
doctor, sought other opinions, understand, and accept the risks from this procedure. By signing below, I do not hesitate to relieve the doctor and his staff from exercising due care on my behalf. I
hereby agree to the stated credit agreement.
I understand that except in an emergency, I will be responsible to pay the full fees of $250.00 for any missed procedure appointments unless cancelled at least twenty-four hours in advance. I
understand that my insurance does not pay for missed appointments and will not be billed.
Patient’s Printed Name:
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