OFFICE USE ONLY – REPEAT PELLET INSERTION FORM MALE NAME: DATE SYMPTOMS/NOTES: PROCEDURE REPORT: The procedure, risks, benefits and alternatives were explained to the patient. Questions were answered and a consent form for the insertion of testosterone pellet implants was signed. An area in the hip was prepped with Chloraprep swabs. A sterile drape was applied. 1% Lidocaine with epinephrine and sodium bicarbonate was injected to anesthetize the area. A small transverse incision was made using a number 11 blade. The trocar with cannula was passed through the incision into the subcutaneous tissue. Testosterone pellet(s) were inserted through the cannula into the subcutaneous tissue. Bleeding was minimal. Steri-strips were applied. A sterile dressing was applied. The patient tolerated the procedure well. Postoperative instructions were reviewed and a copy given to the patient. Weight Testosterone pellet Lot # Testosterone mg Insertion site: Left Hip ( ) Right Hip ( ) DATE SYMPTOMS/NOTES: PROCEDURE REPORT: The procedure, risks, benefits and alternatives were explained to the patient. Questions were answered and a consent form for the insertion of testosterone pellet implants was signed. An area in the hip was prepped with Chloraprep swabs. A sterile drape was applied. 1% Lidocaine with epinephrine and sodium bicarbonate was injected to anesthetize the area. A small transverse incision was made using a number 11 blade. The trocar with cannula was passed through the incision into the subcutaneous tissue. Testosterone pellet(s) were inserted through the cannula into the subcutaneous tissue. Bleeding was minimal. Steri-strips were applied. A sterile dressing was applied. The patient tolerated the procedure well. Postoperative instructions were reviewed and a copy given to the patient. Weight Testosterone pellet Lot # Testosterone mg Insertion site: Left Hip ( ) Right Hip ( )
OFFICE USE ONLY – REPEAT PELLET INSERTION FORM MALE NAME: DATE SYMPTOMS/NOTES: PROCEDURE REPORT: The procedure, risks, benefits and alternatives were explained to the patient. Questions were answered and a consent form for the insertion of testosterone pellet implants was signed. An area in the hip was prepped with Chloraprep swabs. A sterile drape was applied. 1% Lidocaine with epinephrine and sodium bicarbonate was injected to anesthetize the area. A small transverse incision was made using a number 11 blade. The trocar with cannula was passed through the incision into the subcutaneous tissue. Testosterone pellet(s) were inserted through the cannula into the subcutaneous tissue. Bleeding was minimal. Steri-strips were applied. A sterile dressing was applied. The patient tolerated the procedure well. Postoperative instructions were reviewed and a copy given to the patient. Weight Testosterone pellet Lot # Testosterone mg Insertion site: Left Hip ( ) Right Hip ( ) DATE SYMPTOMS/NOTES: PROCEDURE REPORT: The procedure, risks, benefits and alternatives were explained to the patient. Questions were answered and a consent form for the insertion of testosterone pellet implants was signed. An area in the hip was prepped with Chloraprep swabs. A sterile drape was applied. 1% Lidocaine with epinephrine and sodium bicarbonate was injected to anesthetize the area. A small transverse incision was made using a number 11 blade. The trocar with cannula was passed through the incision into the subcutaneous tissue. Testosterone pellet(s) were inserted through the cannula into the subcutaneous tissue. Bleeding was minimal. Steri-strips were applied. A sterile dressing was applied. The patient tolerated the procedure well. Postoperative instructions were reviewed and a copy given to the patient. Weight Testosterone pellet Lot # Testosterone mg Insertion site: Left Hip ( ) Right Hip ( )