VAGINOPLASTY

PROCEDURE DESCRIPTION:

Two surgical options are available.
The vaginoplasty (vulva and vaginal cavity) and the vaginoplasty without cavity (vulva only).

The vaginoplasty without cavity is the same procedure without the cavity dissection and scrotal skin
graft for most cases.

This option will not necessitate the dilation process and will not allow intercourse and no penetration.
The final outside appearance is the same on both options. Ones choice of eithers option is intimate and
personal. In the case where a patient already had a prostatectomy for cancer. The only available option
would be the vaginoplasty without cavity.

The technique used is the one step penile inversion. It is done under general or spinal anaesthesia as
an inpatient in the hospital. The duration is 2 hours. The scrotal skin is removed along with the
testicles. The neoclitoris is fashioned from the tip of the penis (glans) keeping its blood and nerve
supply (neurovascular island flap).

The labia majora are formed with some of the penis skin, the hood and the labia minora with urethral
mucosa and penis skin.

The space for the vagina is dissected behind the meatus (urinary tube) between the bladder and the
rectum. The prostate is left in place because its removal would cause urinary incontinence. The penis
skin is inverted to line the vagina and the thinned scrotal skin graft is sutured to the end of the penis
skin tube. Hair roots on the scrotal skin graft are destroyed with the cautery. A urinary catheter is put
into the bladder, a packing of cotton covered with a condom is put inside the vagina. The prostate is
not removed.

Skin grafts are occasionally necessary. One location for these can be the inner posterior thigh. A split
thickness graft is taken and leaves a discolorated area of skin when healed. This issue will be discussed
with your surgeon preoperatively.


INTENDED RESULTS:

A natural appearing female genital (vulva and vagina) with adequate depth for vaginal intercourse and
normal sensation.


RECUPERATION AND HEALING:

Patient will need to be in Montreal for a 10 days period. One night preoperatively at the Bed and
Breakfast Gite du Marigot or at the recovery center LAsclpiade, 3 nights at the hospital and 6 nights
postoperatively at the recovery center. You should plan to take off work from 6 to 8 weeks.

The evening of the following day of your surgery, you will be moved out of bed and encouraged to sit in
a chair for a while or take a few steps. The morning after, walking is strongly encouraged.


-2-


RISKS:

The specific risks and the suitability of this procedure for a given individual can be determined only at
the time of consultation. All surgical procedures have some degrees of risk. Minor complications that
do not affect the outcome occur occasionally. Major complications are unusual. Please refer to the
Risks for Vaginoplasty for more detailed information.


OTHER PROCEDURE:

Breast augmentation, Adams apple shaving or other cosmetic procedures of reasonable duration can
be done at the same time.

Secondary cosmetic improvements to the vulva are generally not required. Occasionally, patients may
choose to have a revision to enhance the genital details.


PREOPERATIVE SHAVING

Shaved from the navel to mid-thigh all the way around including the testicles and perianal area before
arriving at the hospital or before arriving in Montreal. Do not use wax.


MEDICATIONS TO AVOID BEFORE AND AFTER SURGERY


If you are taking any medication on this list, they should be discontinued at least 15 days prior and
following the surgery. Only Tylenol should be taken for pain. Your doctor prior to surgery must
specifically clear all other medications that you are currently taking. It is absolutely necessary that
your doctor and the nursing staff specifically clear all of your current medication. Natural
products and vitamins must be discontinued at least 15 days prior to surgery. Dont bring hormonal
medical, spironolactone, natural products and vitamins when you will come for your surgery. You do
not need it. Alcohol must be stop at least 7 days prior to and 12 days following surgery.

Do not take Advil

ASPIRIN MEDICATIONS TO AVOID :

4-Way Cold Tabs

5-Aminosalicylic Acid
Acetilsalicylic Acid
Adprin B products

Alka Seltzer products
Amigesic
Anacin products

Anexsia w/Codine

Argesic SA
Arthra-G


Arthriten products

Arthritis Foundation Products
Arthritis pain Formula
Arthritis Strength BC
Arthropan Powder
ASA


Asacol


Ascriptin products
Aspergum


Asprimox products

Axotal
Azdone


Azulfidine products
B-A-C
Backache Maximum
Bayer products

BC powder Strength Relief
Bismatrol products
Buffered Aspirin

Bufferin products
Buffets 11


Buffex


Butal/ASA/Caff
Butalbital Compound
Cama Arthritis Pain Reliever Carisoprodol Compound
Cheracol


Choline Magnesium
Choline Salicylate
Trisalicylate

Cope


Coricidin
Cortisone Medications
Damason P


Darvon Compound 65
Darvon/ASA

Dipentum


Disalcid
Doans products

Dolobid


Dristan
Duragesic


Easprin


Ecotrin products
Empirin products

Equagesic


Excedrin products
Giorgen PF


Fiorinal products

Gelpirin
Genprin


Gensan


Goodys Extra Strength
Halprin products

Headache Powders

Isollyl Improved
Kaodene


Lanorinal


Lortab ASA
Magan


Magnaprin products
Magnesium Salicylate
Magsal


Marnal


Marthritic
Meprobamate

Mesalamine

Methocarbamol
Micrainin


Mobidin


Mobigesic
Momentum

Mono-Gesic

Night-Time Effervescent
Norgesic products

Norwich products

Cold
Olsalazine


Orphengesic products
Oxycodone
P-A-C


Pabalate products

Pain Reliever Tabs
Panasal


Pentasa


Pepto-Bismol
Percodan products

Phenaphen/Codeine #3
Pink Bismuth
Propoxyphene Compound
Robaxisal


Rowasa Products
Roxeprin


Saleto products

Salflex
Salicylate products

Salsalate


Salsitab
Scot-Tussin Original 5-
Sine-off


Sinutab Action
Sodium Salicylate

Sodol Compound

Soma Compound
St. Joseph Aspirin

Sulfasalazine

Supac

Suprax
Triaminicin
Tussanil DH
Vanquish
Zorprin

Synalgos-DC
Tricosal

Tussirex products
Wesprin

Talwin
Trilisaate
Ursinus-Inlay
Willow Bark products

IBUPROFEN MEDICATIONS TO AVOID

Actron


Aleve


Cataflam


Diclofenac


Etodolac


Flurbiprofen

IBU


Ibuprohm


Indomethacin products
Lodine


Mefenamic Acid

Motrin products

Naprelan


Naproxen


Orudis products

Piroxicam


Relafen


Sulindac


Tolmetin

Acular (opthalmic)
Anaprox products
Clinoril

Dimetapp Sinus
Feldene

Genpril

Ibuprin

Indochron E-R
Ketoprofen

Meclofenamate
Menadol

Nabumetone
Naprosyn products
Nuprin

Oruvail

Ponstel

Rhinocaps

Suprofen

Toradol

Advil products
Ansaid
Daypro
Dristan Sinus
Fenoprofen
Haltran
Ibuprofen
Indocin products
Ketorolac
Meclomen
Midol products
Nalfon products
Naprox X
Ocufen (opthalmic)
Oxaprozin
Profenal
Sine-Aid products
Tolectin products
Voltaren

OTHER MEDICATION TO AVOID


4-Way w/ Codeine
Accutrim

Anisindione
BC Tablets

Contac

Dicumerol

Emagrin

Fragmin injection
Heparin

Lovenox injection
Miradon

Pentoxyfylline
Prednisone

Ru-Tuss

Sofarin

Stelzine

Tenuate Dospan
Ticlopidine

Virbamycin
Methotrexate

A-A Compound

Actifed


Anturane


Childrens Advil

Coumadin


Dipyridamole

Enoxaparin injection
Furadantin


Hydrocortisone

Macrodantin

Opasal


Persantine


Protamine


Salatin


Soltice


Sulfinpyrazone

Thorazine


Trental


Vitamin E


Remicade (infliximab)

A.C.A.
Anexsia
Arthritis Bufferin
Clinoril C
Dalteparin injuection
Doxycycline
Flagyl
Garlic
Isollyl
Mellaril
Pan-PAC
Phenylpropanolamine
Pyrroxate
Sinex
Sparine
Tenuate
Ticlid
Ursinus
Warfarin
Accutane (6 months before)

TRICYCLIC ANTIDEPRESSANT MEDICATIONS TO AVOID

Adapin
Anafranil
Climipramine
Elavil
Imipramine
Ludiomil
Nortriptyline
Protriptyline
Tofranil
Vivactil

Amitriptyline
Asendin
Desipramine
Endep
Janimine
Maprotiline
Pamelor
Sinequan
Triavil

Amoxapine
Aventyl
Doxepin
Etrafon products
Limbitrol products
Norpramin
Perfofrane
Surmontil
Trimipramine


PREPARING AT HOME FOR A VAGINOPLASTY



STARTING NOW: STOP SMOKING


Smoking reduces blood circulation, impedes healing and is a cause of pulmonary complications
following major surgery and general anaesthesia.


DIET AND EXERCISE:

If you do not participate already in regular physical activities you should consider discussing this issue
with your physician and take the necessary steps towards entering a program that suits you. A healthy
and well balanced diet should be part of your every day life. Overweight can be a cause of cancellation.


THREE WEEKS BEFORE SURGERY:

Stop taking hormone medications: oestrogen, progesterone and spironolactone. Stop also natural
products and vitamins. Dont bring your hormonal medication and any kind of vitamins minerals or
natural product, you will take them back home.

Herbal remedies can interfere with blood clotting and must be stopped.

Medications to avoid:

Advil and Aspirin, non steroidal anti-inflammatory drugs must be stopped to avoid bleeding problems
during and after surgery. Acetaminophen is fine. Please refer to the Medication to avoid .



ONE WEEK BEFORE SURGERY:

Alcohol:

No alcoholic beverages should be taken the week preceding surgery.

Nails:

If you are wearing artificial or acrylic nails, you have to remove them on both index fingers. Those
fingers will be used to monitor blood oxygen saturation during surgery. Do not wait for the last minute
some nails are difficult to remove them on both index fingers.

ARTICLES TO BRING WITH YOU FOR YOUR HOSPITALIZATION
VAGINOPLASTY


HERE ARE SOME ARTICLES THAT WILL BE USEFUL DURING YOUR HOSPITAL STAY:

A mirror that can be propped up in your bed to help with visualization during dilations.
Three sets of clothing changes and ensure that the clothing items are loose fitting.
Enclosed non-skid slippers with a rubber sole.
Three sets of pajamas and a bathrobe.
Three pairs of cotton underwear.
Bring soap Dove or Ivory unscented.
Personal items: toothbrush, toothpaste, comb, brush, unscented lotion, shampoo,
pocket change, long distance telephone card, credit card, medicare
card (QC residents), computer, books, crossword puzzles, iPod
things to keep you entertained during your hospital stay.
Small travelling bag for hospital transfers during your stay.
Your suitcase should be large enough to accommodate additional items that will be given to
you during your hospital stay.
Avoid having too heavy luggage (maximum 40 pounds) for our staff.
Surgery consent form.


IMPORTANT: Please bring all your current medications (except hormone) in their original
containers as well as the medication(s) you only take occasionally. Please
obtain this medication list from your pharmacist as well as an updated list of
your allergies, as we will ask you to submit this on the day of your admission.

ARTICLES TO PURCHASE FOR YOUR RETURN HOME

TO BE PURCHASED PRIOR TO YOUR SURGERY AND LEFT AT HOME


One vaginal douche keep this vaginal douche container for future refills solution of saline water.
Antibacterial dishwashing soap for your dilators with.
Ten tubes of lubricating gel (140g) K-Y or another brand consisting of a water based solution.
Four packs of unscented sanitary napkins (light absorption).
One box of disposable blue pads to protect your bed linens (use during dilations).
Two packs of disposable non-perfumed baby wipes.

1.
2.
3.
4.
5.
6.

NOTE:

Arrange to have all your housework done, pre-prepared meals frozen and ready to go,
non-perishable groceries purchased prior to your surgery. It is advisable to have a
support system in place for your arrival home to assist you during your first week
home.



ELECTROLYSIS



Hair removal on external genitals before male to female reassignment surgery is debatable.

Hair bearing skin on the penis shaft base with the one step technique stays outside the neo vagina. The
skin that will become the internal lining of the new female genital is the rest of the penis skin, scrotal
skin and a small perineal flap ( a one square inch of skin that is located one side above the anal
margin on the midline ). If you want a perfect hair free vagina, you need to be sure that no regrowth of
hair has occurred on the area for at least one year after you have finished electrolysis with laser. Even
then, this does not guaranty that no hair will ever grow.


The hair roots are either killed or weakened by electrolysis or laser. Those only weakened will regrow.
During surgery hair roots are killed with the cautery on the scrotal skin that is used as a graft ( not on
the perineal flap ). During surgery, the hair roots that were weakened are less visible because they
are much smaller than those found untreated areas and could be missed by the surgeon and regrow
later. For this reason, in our experience, expeditive laser or electrolysis treatments are worse than not
having hair removal at all. In fact, we can get most hair roots during surgery if they were not
weakened. Regrowth after our surgery is possible but very sparse.

If you want no regrowth at all, you will have to face hours of pain having hair removed and a one year
none growth period.

At this time, we do not feel that hair removal is indicated.


DAILY SCHEDULE IN MONTREAL FOR VAGINOPLASTY


This is a general indication for the schedule following your arrival in the city of Montral. Since
complications do not often occur, if a complication should arise, your schedule will be adjusted
accordingly. Please feel free to contact us if you have any questions.


AIRPORT-BUS OR TRAIN STATION IF YOU ARE NON CANADIAN CITIZEN :

At the Customs, have a passport. Since January 2007, you need a passport to come in Canada. If
you have a problem at the Customs, a form is included to present to Canadian Customs but
show this letter only if Canadian Customs ask for more information or details.


WHEN CLEARED FROM CANADIAN CUSTOMS FOR NON CANADIAN CITEZEN:

Call Mr ROBERT CLERK (limousine driver) at: 514 591-4284, who will drive you to the recovery
center located at 908 Gouin west Montreal Quebec or at the Bed and Breakfast Gite du Marigot
(www.gitedumarigot.com) phone number: 450 668 0311.


WHEN CLEARED FROM THE HOSPITAL:

You will go to the recovery center LAsclpiade at 908 Gouin ouest, Montral Que. H3L 1L2
phone number: 514 333-1572.


DAY BEFORE SURGERY:

You should plan this day so that you pay particular attention to bowel preparation. Shaving should be
done at bed and breakfast Gite du Marigot the day before your surgery. Both index nails should be
ready for oxymetry.

Bowel preparation: one fleet enema during the afternoon around 4:00 p.m. You can have a normal
meal for dinner. One fleet enema at 8:00 in the evening at the hospital.

Departure from the Bed and Breakfast is at 7:00 p.m. When you arrive at the hospital, the nurse will do
your admission. If you have to take medication during your stay at the hospital, give them to the
admission nurse. You will be given your room which you share with another patient who usually as
the same type of surgery. In the room, there is a small safe for your important papers (money, credit
cards, etc). We recommend that you put all the things you will need at the hospital in separate suitcase
(See items to bring to the hospital). The time of your surgery is decided only the morning of the
surgery by the staffs that coordinate the work in the operating room, the recovery room and the wards.

If there is no specific coordination to make, then the order of the surgeries is randomly decided.
Starting at midnight, you must have nothing to eat or drink until after your surgery.


-2-

MORNING OF THE SURGERY:


You should pay particular attention to have your genital from navel to anal area including your penis
shaft and scrotal skin shaved. Give yourself enough time to perform this before your surgeon and the
anaesthesiologist visits if you did not shaved properly at the Bed and Breakfast.

That morning, you should expect your surgeon and anaesthesiologist to meet with you in your room
and that is usually done before 7:00 oclock. If you want to shower the morning of the surgery, it
should be done very early and your hair should be dry. You must not drink or eat the morning of the
surgery. The anaesthesiologist may allow you to have juice before 8:00 oclock if the surgery is not
early in the morning. This decision belongs to him. Your surgery is going to be under general or
regional anaesthesia. You will spend one hour in the recovery room. If you have friends or spouse
accompanying you, they can be with you all the time, except for the time in the operating room and
recovery room. They should not expect to have their meals or be able to sleep at the Clinic. If they
want to speak with you after the surgery, they should expect that you will be drugged for the rest of
the day. If they want to spend time in your room after the surgery, they are welcome to do so, but as
you understand, they have to let the staff do their work for you. They should leave at least 8:30 p.m.
Early in the morning, before the surgery, you will be given two pills of Celebrex 100mg, unless contra-
indicated, which is an anti-inflammatory agent that will work on the pain process before it starts. This
will lower the pain after the surgery. Right after the surgery, you will have an I.V. in your arm, a
dressing and ice packs on your genitals. Do not expect to remember much of the day events.


FIRST AND SECOND DAY AFTER SURGERY:


You must stay in bed more than 24 hours after your surgery. The evening of the day following your
surgery, you will be allowed to sit up and stand up: you must be helped by the staff to do that. Light
diet and oral fluids will be started on the first operative day. During the first 48 hours, you should
expect to have some bleeding in your dressing which is normal. That bleeding usually stops during the
first day after surgery and varies from a person to another. Your surgeon will make sure on a day-to-
day basis that this stays within the range of normal. You will also notice swelling and bruising. The
bruising can spread up to the navel and down to the thighs. It takes sometime, 3 to 4 weeks, to go
away. The I.V. will be removed on the second day post-op.


THIRD AND FOURTH POST-OPERATIVE DAY:


During those days, your activities will be limited to walking in the recovery center, have your meals,
medication and have regular exams by the staff and your doctor. A bowel movement usually happens 5
days after surgery. Stool softeners are given starting on day two postoperatively. Do not strain to
evacuate.



-3-


Once you are walking in the recovery center, you have to put a plug at the end of the catheter. You will
go to the bathroom to empty your bladder through your catheter. Sometimes, and this happens
regularly, urine can come around the catheter and wet your dressing. When the dressing is removed,
you can still have some urine leaking. This is not a problem. If you still have your dressing on, and this
happens, you will have the impression that urinating creates bleeding, but in reality, this is dry blood
that is wet again and drips out the dressing. Urine is sterile and will not affect negatively your result.

At the recovery center you will be directed to your room. You will meet the nurse who will teach you
how to take care of your surgery site. Also, directions will be given to you regarding your post
operative-medications. If you are active, your doctor may allow you to resume your hormones. You
should always ask him if he has not given you the permission. The catheter will stay in place for 5 days
after your surgery. You may take a bath or shower with the catheter and the stent in place. Use clear
dishwasher soap provided for baths (a good disinfectant).


DAY OF YOUR FIRST DILATION:


Early in the morning, the nurse will remove your stent. Although uncomfortable at first, the removal of
it is a relief. You will feel much better then. It is advised to lay on your bed for a short period (10
minutes) after that. Plan on preparing for a pad in your panties. It will be useful when you walk
because fluid usually accumulates in your vagina and comes out when the stent is removed. The nurse
at the recovery center will show Douching and dilations to you. Do not start before she teaches you.
During the next days, your nurse will make sure you are healing well and will explain to you your new
anatomy. It is very important that your drink water in good quantity (8 glasses per day) to avoid
infection.



Rev. April/09


SPECIFIC POST OPERATIVE INSTRUCTIONS:



MEDICATIONS TO TAKE AFTER YOUR SURGERY:

Your surgeon will write an order and the hospital head nurse will make sure that you receive your
medications when you are at the recovery center. You should not take any hormones until you are
authorized to do so. Any other medication that are on the list Medications to Avoid must be
avoided for another month.

CARE OF YOUR SURGERY SITES:
The nurse at the recovery center will show you how to take care of your surgery sites after your
arrival.


DILATION AND DOUCHING:
Since this is a newly created vagina, it is necessary to gently dilate the vagina with the set of vaginal
dilators provided. This is critical to maintain the vaginal vault and prevent the vagina from narrowing
and collapsing. It will also help to increase the width of the vagina.


URINARY CATHETER AND STENT REMOVAL:
A urinary catheter will be left in the bladder for 5 days. After the catheter is removed, you will be able
to urinate while sitting. The sensation to void is unchanged. Occasionally, patients may not be able to
urinate after the catheter is removed. This is a temporary problem caused by swelling around the
urethra. The catheter must be replaced, and should remain for at least 1 week. You can still return
home as planned, and have your personal physician remove the catheter. The urethra is shorter, so
you will be more susceptible to urinary tract infections. Therefore, it is important to drink abundant
fluids following surgery to prevent this. Spraying is usual for the first four months. As swelling
subsides, it will slowly decrease to a normal stream.
A stent is placed inside the vagina and dressing is placed on the vulva after surgery. It is common for
patients to drain some blood into these dressings, which will need frequent changes for the first few
days. Following this, a maxi pad or similar sanitary napkin is adequate. It is common for patients to
have vaginal drainage for at least a month after surgery. The cotton packing on the vulva will be
removed on the 4th day after surgery. The stent will be removed (by the nurse) on the fifth day after
surgery and you will be instructed on the vaginal dilation.


LABIAL SWELLING:
All patients will have some swelling of the labia to variable degrees. Keeping ice on the perineum for
the first few days after surgery can reduce this. This swelling can take up to six weeks to resolve. The
vulva will approach its final appearance at 4 months. Healing of scars will take one year.


-2-


ACTIVITIES:
The level of discomfort improves daily, and frequently when people go home they are no longer taking
pain medication. For the first 4 weeks following surgery, there should be no heavy lifting or straining.
After 2 weeks you may begin returning to your normal activities. Let your own comfort and the
amount of swelling you experience guides you. If possible, you should take 4 to 6 weeks off work.

SEXUAL INTERCOURSE:
Sexual intercourse is permitted 3 months after surgery. Lubrication will probably be necessary

VAGINAL LUBRICATION:
Although some patients will have enough secretion through the urethra for adequate lubrication
during vaginal intercourse, most patients will need some form of vaginal lubricant.

YEAST INFECTION:
Vaginal yeast infections are occasionally a side effect of antibiotic therapy, and can be treated topically
or orally. The symptoms of a yeast infection are: an intense burning itch of the vagina, labia or
surrounding tissue; red, blotchy rash on the genital area; occasionally a white discharge.
If you develop any of these symptoms, contact our office or your general practitioner.
To avoid yeast infection, wear all cotton underwear and avoid tight, restrictive clothing during the day
and at night.
Your urethra is now much shorter. The potential for bacteria travelling up the urethra and the bladder,
causing a urinary tract infection (bladder infection) is now much higher.

Symptoms of a urinary tract infection are: pain and burning when you pass urine; hesitancy or inability
to initiate urination; feeling the need to pass urine frequently and only passing small amounts; pain in
the lower abdominal area and/or mid back; blood, cloudiness or debris in the urine, fever; nausea.
If you develop any of these symptoms contact your general practitioner.
Good habits to practice to help avoiding bladder infections are: drink plenty of fluids, at least eight (8)
oz glasses of fluid per day; pass urine every 2-4 hours, avoid wearing tight clothing; always wipe
front to back .

MEDICAL FOLLOW UP:
A vaginal exam, including a speculum exam should be done yearly. A prostate examination should also
be performed. Any primary care doctor or gynecologist can do this. It is very important that you be
honest with the examining physician.
Your prostate is not removed and it can be felt through the vagina.

SWIMMING/HOT TUB:
Hot tubs and swimming in a lake or pool should be avoided during 2 months.

Rev. April/09


SPECIFIC AS YOUR HEAL INFORMATION:


BRUISING :

Bruising after surgery is normal. It can be limited to the genitals or be more extensive: flanks, lower
abdomen and thighs. It will resolve in the first few weeks (3-4 weeks)


SWELLING:

Swelling of the labia and moms pubis is normal. Most of it will resolve in the first month. It will take at
least 4 months for complete disappearance. Prolonged sitting and standing can aggravate this.

The area over the pubic bone may remain swollen and firm for several months. When it no longer feels
tender you may massage the area for 10 minutes a day. This will help the swelling to reduce faster.


SUTURES:

Once the dressing, catheter and stent are removed, all the outside and inside sutures are restorable.
For some of them it will take two months to resorb.

The dressing sutures (3 or 4) are removed on day 3 or 4 after your surgery. The stent sutures are
removed after 6 or 7 days.


SENSATION:

During the early phases of healing it is not unusual to have some areas of numbness of the labial and
moms. This should improve over the first few months after surgery. Permanent numbness of these
areas is very rare. Sensory nerves take sometimes 12 to 18 months to heal.


VAGINAL DISCHARGE:

Collared vaginal discharge (brown and/or yellow) is expected for the first 6 to 8 weeks as the inside
lining of the vagina heals. Also skin sloughing (skin graft residues) can come out especially during the
first month. Douching during these phases will help to keep the inside of the vagina clean and infection
free. See douching instructions in this package.


AREAS OF DELAYED HEALING:

Occasionally patients will experience areas of delayed healing especially at the entrance of the vagina,
along the suture lives and inside the vagina. These should be treated with an antibiotic ointment. The
area (s) will heal quickly. If there is no improvement with the use of ointment after 3-4 weeks, you
should call your surgeon. Then the use of silver nitrate (AgNO3) applicators can be useful.


-2-


URINATION:

Urination after the catheter is removed is usually easy. However for some, it can be more difficult. If
you have not urinated the afternoon of the first day of dilation, we may have to put a catheter back for a
few more days (at least two). If your urination is possible but difficult, please tell the nursing staff at
the recovery center, FLOMAX pills can be given then to ease the process.

Urination physiology is altered by the creation of a vaginal space and internal swelling. This should
resolve within the first 3 to 4 months.


BOWEL MOVEMENTS:

You may experience difficulty in the beginning to have your first BM because of the medications
prescribed (the narcotics slow your intestines) or because youre daily usual routine was changed by
surgery. Prune juice and laxative will help to get you back to regularity. A glycerine suppository or
enemas are used as last resort. Your first BM should happen within the first 5 days post op. On the
fifth day post-op please advise us if no BM has occurred.

It is essential to keep your operated area as clean and dry as possible. Therefore, at least one bath per
day with dishwasher soap or sits baths. Clean area thoroughly after each bowel movement. Wash your
hand often.

Use disposable wipes after each bowel movement to clean anal area. Always wipe towards the rear so
as not to prevent contamination of the vagina and the vulve.


BATHS:

You should have a shower every day.


VAGINAL DILATION:

In some patients, vaginal dilation may be difficult and uncomfortable. But over the first month, this
usually gets much easier. As long as you are maintaining the original depth of the vagina there is no
reason to be concerned. Sometimes it just takes longer to advance to the larger width dilators. Be
patient, and dont force the dilator. Increasing the width of the vagina becomes easier as the swelling
improves.

Dilations must never be stopped without advising your surgeon.

SURGICAL RISKS FOR VAGINOPLASTY

We want you to understand fully the risks involved in surgery so that you can make an informed
decision. Although complications are infrequent, all surgeries have some degrees of risk. All of us will
use our expertise and knowledge to avoid complications so far as we are able. If a complication does
occur, we will use those same skills in an attempt to solve the problem quickly. The importance of
having a highly qualified medical team and the use of a certified facility cannot be overestimated.

In general, the least serious problems occur more often and the more serious problems occur rarely.

If a complication does arise, we will need your cooperation in order to resolve the problem.
Complications usually involve an extension of the recovery period rather than any permanent effect on
your final result.


SIDE EFFECTS

SWELLING AND BRUISING:

Moderate swelling and bruising are normal after any surgery. Severe swelling and bruising may
indicate bleeding or possible infection.

DISCOMFORT AND PAIN:

Mild to moderate discomfort or pain is normal after any surgery. If they are not controlled well with
your medications, please advise me.

CRUSTING ALONG THE INCISION LINES:

We usually treat this with antibiotic ointment.

NUMBNESS

Small sensory nerves to the skin surface are occasionally cut when the incision is made or interrupted
by undermining of the skin during surgery. The sensation in those areas gradually returns, usually
within the first year as the nerve endings heal spontaneously.

ITCHING:

Itching and occasional small shooting electrical sensations within the skin frequently occur as the
nerve endings heal. Ice, skin moisturizers, and massages are frequently helpful. These symptoms are
common during the recovery period.

REDNESS OF SCARS:

All new scars are red, dark pink, or purple. Scars may take up to one year or longer to fade.


Initial: ______


-2-

COMPLICATIONS

BLOOD LOSS:

Bleeding is a risk of any operation. Genital and perineum surgery is an area of special concern.
However the need for transfusion would be very rare (approx. 1 to 1000 cases). If you are particularly
concerned about a transfusion, you can give your own blood in advance. We do not recommend it
however as a routine procedure.

HEMATOMA:

Small collections of blood under the skin are usually allowed to absorb spontaneously. Larger
hematomas may require aspiration, drainage, or even surgical removal to achieve the best result. Five
percent of patients may develop a hematoma.

INFLAMMATION AND INFECTION:

A superficial infection may require antibiotic ointment. Deeper infections are treated with antibiotics.
Development of an abscess usually requires drainage. Infections may develop in 1% of patients.

Infection is a standard risk for all surgical procedures. You will receive prophylactic antibiotics during
the first two weeks.

WOUND SEPARATION OR DELAYED HEALING:

Any incision, during the healing phase, may separate or heal unusually slow for a number of reasons.
These include inflammation, infection, wound tension, decreased circulation, smoking or excess
external pressure. If delayed healing occurs, the final outcome is usually not significantly affected, but
secondary revision of the scar may be indicated.

SENSITIVITY OR ALLERGY TO DRESSINGS OR TAPE:

Occasionally, allergic or sensitivity reactions may occur from soaps, ointments, tape or sutures used
during or after surgery. Such problems are unusual and are usually mild and easily treated. In
extremely rare circumstances, allergic reactions can be severe and require aggressive treatment or
even hospitalization.

INCREASED RISKS FOR SMOKERS:

Smokers have a greater chance of skin loss and poor healing because of decreased skin circulation. (See
preparing for surgery)

INJURY TO DEEPER STRUCTURES:

Blood vessels, nerves and muscles may be injured during surgery. The incidence of such injuries is
rare.

Initial: ______


-3-

LOSS OF SENSATION:

Since the nerves to the glans are preserved, there should be excellent sensation. Initially, following
surgery, there may be patchy areas of numbness from stretching and swelling. But this should return
to normal within several months. Rarely, small areas of numbness may persist. It is remotely possible
that the clitoris may not survive.

LOSS OF SEXUAL FUNCTIONS:

Although a majority of patients will be orgasmic following surgery. It is possible that the sexual
potency or the ability to achieve orgasm could be affected.

RECTAL INJURY OR RECTOVAGINAL FISTULA:

The most concerning complication is the creation of an abnormal path between the rectum and the
vagina, called a rectovaginal fistula. Should this occur, both gas and feces could come through the
vagina. Secondary operations would be necessary to close the fistula and to recreate a vaginal canal
often with skin grafts. This has been a rare complication in our experience (about 0,5%)

INCISIONS (scars)

The majority of the scars are located in the labia and will be covered by pubic hair. There are three
small scars located on the labia outside areas, which are from retention sutures.

If skin grafts are necessary, there will be donor site scar usually on the inner posterior thigh. Redness
of the scars to a variable extent will occur once you return to normal activities. These scars will usually
fade in color gradually after a year and leave a discolorated area.

THICK, WIDE, OR DEPRESSED SCARS:

Abnormal scars may occur even though we have used the most modern plastic surgery techniques.
Injection of steroids on the scars, placement of silicone sheeting into the scars, or further surgery to
correct the scars is occasionally necessary. Some areas on the body scar more than others, and some
people scar more than others do. Your own history of scarring should give you some indication of
what you can expect.

COMPARTMENT SYNDROME AND NERVE INJURY OF THE LEGS

Though it is very uncommon. There have been reports of nerve injury in the legs or injury to the
muscles (compartment syndrome) associated with positioning of the patient in stirrups. If
compartment syndrome of the leg occurs, then the muscles must be surgically released. This is a very
unusual complication that we take every precaution to prevent with padding of the legs and careful
positioning in surgery.

Occasionally patients experience areas of numbness or a change in sensation on the skin of the legs,
especially the thigh. This is usually temporary with normal sensation returning within several months.
Rarely it is permanent.
Initial: ______


-4-

RARER COMPLICATIONS:

If they are severe, any of the problems mentioned may significantly delay healing or necessitate further
surgical procedures.

Medical complications such as pulmonary embolism, severe allergic reactions to medications, cardiac
arrhythmias, heart attack, and hyperthermia are rare but serious and life threatening problems.
Having a board certified anaesthesiologist present at your surgery reduces these risks as much as
possible. (Failure to disclose all pertinent medical data before surgery may cause serious problems for
you and for the medical team during surgery).


UNSATISFACTORY RESULT & NEED FOR REVISIONAL SURGERY:

All plastic surgery treatments and operations are performed to improve a condition, a problem or
appearance. While the procedures are performed with a very high probability of success,
disappointments occur and results are not always acceptable to patients or to the surgeon. Secondary
procedures or treatments may be indicated. Rarely, problems witch may occur are permanent.

Poor results: asymmetry, unhappiness with the result, poor healing, etc. may occur. Minimal
differences are usually acceptable. Larger differences frequently require revisional surgery.


BLOOD CLOTS AND PULMONARY EMBOLISM:

These problems can occur rarely with any surgery, but are a little more common in pelvic procedures
and in patients on supplemental hormone therapy. Stopping hormone therapy 3 weeks before
surgery, shortened operating time, post-operative leg movements, and walking soon after surgery will
help to avoid these problems. Although pulmonary embolism and blood clots can be life threatening.
They usually resolve completely with hospitalization and care by a medical specialist.


UROLOGICAL COMPLICATIONS:

All patients will be able to urinate while sitting; however it is usual to have spraying of the urine until
the swelling resolves (sometimes 4 months). An abnormal narrowing of the urethra (stricture), an
abnormal communication between the urethra and vagina (urethro-vaginal fistula) and urination
physiology disturbances with secondary urinary infections can occur. Some of these complications
may require urological intervention.

We have outlined the common and not-so-common risks of surgery in general. The specific risks and
complications of each surgical procedure have been explained elsewhere in this preoperative package.
We have not discussed every possible problem that may occur, and you cannot assume that a problem
will not occur simply because it is not discussed here.

Initial: ______


-5-


I acknowledge that the risks and complications of the surgery I am to undergo have been explained and
discussed with me in detail by Dr _________________________________. I have been given the opportunity to
ask questions and any concern I had about my surgery have been explained to me. My signature here
attests to my understanding and satisfaction with the answers I have been given.



SIGNATURE : _______________________________
DATE ____________________________


WHITNESS : ________________________________


CONSENT FOR SURGERY: VAGINOPLASTY




I, the undersigned, being of perfectly sound mind, make the following declarations:


Following various consultations with the following specialists:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


who are all in agreement with my desire for sex reassignment surgery, I have asked Doctor Pierre
Brassard and Doctor Maud Blanger to proceed with the transsexual intervention : VAGINOPLASTY
USING PENILE INVERSION TECHNIQUE (SEX CHANGE CREATION OF VAGINA AND VULVA)


The nature and purpose of the operation (s) possible alternative methods of treatment (sigmoid colon
vaginoplasty) including no treatment/surgery, risks and possible complications have been fully
explained to me by Dr Pierre Brassard during my preoperative consultation. I understand that this
operation is not an emergency nor is it medically necessary to improve or protect my physical health. I
have been advised that all surgery involves general risks, including but not limited to bleeding,
infection, nerve or tissue damage and, rarely, cardiac arrest death, or other serious bodily injury. I
acknowledge that no guarantees or assurances have been made as to the result that may be obtained.


Thus in accurate terms, I understand that the correct surgical procedure is as follows:


-"There will be an amputation of the penis."


-"The two (2) testicles removed, the scrotal skin will serve as a tentative construction of a
vulva."


-"The urethra will be grafted to the normal vulvar area for a woman."


-"By means of a penile skin flap (penile skin and sometime scrotal skin) we shall attempt to
construct a cavity between the bladder and the rectum. This new grafted vaginal cavity should be
maintained opened by dilatations, which the frequency etc. has been explained in the post-op
instructions.


It has been explained to me that during the course of the operation unforeseen conditions may be
revealed that necessitate an extension of the original procedure (additional skin grafts) and I hereby
authorize my doctor and/or such assistants as may be selected by him/her to perform such
procedures as are necessary and desirable, including but not limited to the service of pathologists,
radiologists, or a laboratory. The authority granted in this paragraph shall extend to remedying
conditions that are not known to my doctor at the time the operation commences.


-2-



Therefore, I understand precisely, as this has been explained to me.

A
- That it is an "apparent", "visible" sex change, and that after the operation, I shall not have any
female organs which would enable me to have children or to have menstrual periods;

B
- That the operation is absolutely irreversible, that is, once the penis and testicles removed, it
will be impossible to "remake" new ones;

C
- That after the operation, I shall no longer be able to have masculine orgasms, the sexual
satisfaction that I may obtain will be above all psychological;

D
- That for the rest of my life, I shall have to follow hormonal treatments with the hope to obtain
and maintain breasts of a feminine appearance, and also a feminine capillarity.


I understand that this surgical intervention comprises risks as in all major surgical
interventions, and in a case such as this one, a recto-vaginal or urethro-vaginal fistula is possible. The
other possible complications are the following: infection, bleeding, vicious scarring, partial or complete
vaginal stenosis or partial or complete necrosis of the skin graft, urethral stenosis, etc... I realize that
the medical team and the hospital staff can in no way promise me the success of this operation.


I therefore wish to assume by myself all the inherent risks of such a surgical intervention
hoping that it will enable me to be physically more consistent to any personality and psychological
needs.

I understand that photography is important in planning and evaluating surgery, and I give permission
for photographs to be taken before, during and after my surgery for the purposes of documentation
only.


I pledge myself not to take any steps for and to refuse all offers concerning publicity and for a
publication relative to my antecedents, to this intervention and its results.


Moreover, I am fully conscious that I may encounter certain other problems relative to my civil
status and I assume these also by myself.


I declare having read this declaration, having perfectly understood all its implications, and it is
in all liberty that



I signed . . . . . . . . . . . . . . on this . . . .day of . . . .20 . .


Witnesses:

. . . . . . . . . . . . . . . . . . .


. . . . . . . . . . . . . . . . . . .

INFORMED-CONSENT-SKIN GRAFT SURGERY FOR VAGINOPLASTY

Additional skin grafts may be necessary during vaginoplasty to allow the construction of adequate
depth of the vagina.


INSTRUCTIONS
This is an informed-consent document that has been prepared to inform you of skin graft surgery, its
risks, as well as alternative treatments.
It is important that you read this information carefully and completely. Please initial each page,
indicating that you have read the page and sign the consent for surgery as proposed by your plastic
surgeon.

INTRODUCTION
Skin graft surgery is frequently performed by plastic surgeons to use skin taken from another area of
the body to restore skin coverage in other area(s). Skin grafts help wounds heal that otherwise would
not heal adequately. Skin grafts are useful in situations where there is adequate subcutaneous tissues
present to provide support and blood supply for the skin graft.
Skin grafts are generally classified as to the thickness of the skin that is being grafted from one part of
the body to some other region. A split-thickness skin graft does not comprise the entire thickness of
skin. The donor area where the split-thickness graft is taken can heal on its own. Large areas of the
body can be used for split-thickness skin grafts. The full thickness skin graft is different as it involves
the full thickness of skin and deeper tissues. Full-thickness grafts tend to be used for specific wound
coverage applications when thicker skin is needed. The donor area for the full thickness graft is limited
in size as full-thickness skin graft donor sites cannot be used more than one time.
Skin grafts are an effective means of assisting wound healing when there has been a loss of skin due to
conditions that involve disease, injuries including burns, or surgical removal of tumors. Some wounds
may be too complex to heal without other more involved reconstructive techniques. In some
situations, surgical procedure(s) and other treatments (dressing changes and hydrotherapy) may be
needed to prepare a wound for a skin graft.

ALTERNATIVE TREATMENTS
Alternative forms of care consist of not undergoing surgery. Some minor wounds may heal without
surgery. In other situations, different forms of treatment such as the transfer of skin and other
composite pieces of tissue may be preferable to skin grafts. Microsurgical tissue transfer may be
necessary in situations when ordinary surgical techniques cannot provide for satisfactory tissue to
cover a complex wound.
Risks and potential complications are associated with alternative forms of treatment. Although
wounds can heal spontaneously, there may be increased risk of unsatisfactory result, scarring, and
functional impairment.

Page 1 of 5

Patient Initials

10-01-00 version

RISKS of SKIN GRAFT SURGERY

Every surgical procedure involves a certain amount of risk and it is important that you understand the
risks involved with skin graft surgery. An individuals choice to undergo a surgical procedure is based
on the comparison of the risk to potential benefit. Although the majority of patients do not experience
the following complications, you should discuss each of them with your plastic surgeon to make sure
you understand all possible consequences of skin graft surgery.


Bleeding- It is possible, though unusual, to experience a bleeding episode during or after surgery.
Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood
(hematoma). Do not take any aspirin or anti-inflammatory medications for ten days before surgery, as
this may increase the risk of bleeding. Non-prescription herbs and dietary supplements can increase
the risk of surgical bleeding.


Infection- Infections after skin graft surgery may occur. Additional treatment may be required. There
is the possibility of skin graft failure or scarring from an infection. Should an infection occur, treatment
including antibiotics or additional surgery may be necessary.


Itching- Itching is a common complaint in both the skin graft donor location and the recipient location.
Itching may be a chronic complaint. Graft abrasion may occur from scratching.


Inability to heal- Conditions that involve disease, injuries including burns, or surgical removal of
tumors can produce severe wounds. Skin grafts require adequate blood supply for survival. Areas of
the body where there is inadequate blood supply due to injury, disease states, or the effect of radiation
therapy, may not be capable of providing adequate blood supply for skin graft survival. Skin grafts are
also vulnerable to loss in disease situations where there is a propensity for chronic swelling or vascular
insufficiency disorders. Some wounds may be of the extent and severity that skin grafts cannot
produce closure of the wound and healing. More involved reconstructive surgical procedures may be
necessary.


Skin scarring- Excessive scarring can occur. In rare cases, abnormal scars may result. Scars may be
unattractive and of different color than surrounding skin. Scarring may limit joint and extremity
function. Special compressive garments may be needed to help control scarring. Additional
treatments including surgery may be necessary to treat abnormal scarring.


Skin sensation- Diminished (or loss) of skin sensation in the donor location for the graft as well as the
location where the graft is placed may occur and not totally resolve after skin graft surgery. Skin grafts
generally do not regain normal skin sensation. Injuries may occur secondary to this lack of sensation if
the skin graft is subjected to excessive heat, cold, or physical force. Skin grafts placed in areas of
decreased sensation are prone to injury and loss. Care must be given to avoid injury to these areas or
complications may occur.


Skin contour irregularities- Contour irregularities and depressions may occur after skin graft
surgery. Visible and palpable wrinkling of skin can occur. If a skin graft has been processed in a graft
meshing device, it may heal with a pattern.


Page 2 of 5

Patient Initials



10-01-00
version


Delayed healing - Scarring and inadequate healing may occur in the location where the skin graft is
taken for transfer to other parts of the body. Healing of the donor area may take unacceptably long
periods of time. The donor area once healed may be prone to abrasions. The skin graft may heal
abnormally or slowly.


Color change- Skin grafts and the skin graft donor location can undergo changes in color. It is possible
to have these areas be either darker or lighter than surrounding skin. These changes can be
permanent. Additionally, these areas may have exaggerated responses with changes in skin color to
hot or cold temperatures.


Inability to restore function- In some situations, skin grafts cannot restore the normal function of
intact skin or undamaged deeper structures. Although it may be possible to produce healing with a
skin graft, there can be a loss of function. Additional treatment and surgery may be necessary.


Patient failure to follow through- Its important that the skin graft is not subjected to excessive force,
swelling, abrasion, or motion during the time of healing or graft loss may occur. Skin graft donor
locations are similarly vulnerable to injury during the healing process. Personal and vocational activity
needs to be restricted. Protective dressings and splints should not be removed unless instructed by
your plastic surgeon or hand therapist. Successful restoration of function may depend on both surgery
and subsequent rehabilitation. You may be advised to wear compressive garments to control both
swelling and scarring following skin graft surgery. It is important that you participate both in follow-
up care and rehabilitation after surgery.


Surgical anesthesia- Both local and general anesthesia involve risk. There is the possibility of
complications, injury, and even death from all forms of surgical anesthesia or sedation.


Unsatisfactory result- There is the possibility of an unsatisfactory result from skin graft surgery. This
would include risks such as skin and soft tissue loss, wound disruption, chronic pain and loss of
function. There may be unacceptable cosmetic deformities from skin grafts placed on visible portions
of the body or in the skin graft donor areas. Abnormal color of skin graft and graft origin location may
occur.

Damage to associate structures- Structures such as nerves, blood vessels, and soft tissues may be
damaged during surgery.

Allergic reactions- In rare cases, local allergies to tape, suture material, or topical preparations have
been reported. Systemic reactions that are more serious may result from drugs used during surgery
and prescription medicines. Allergic reactions may require additional treatment.

Skin cancer in skin grafts- Skin cancer can rarely occur in skin grafts.



Page 3 of 5 Patient Initials

10-01-00 version



Pain- Chronic pain may occur very infrequently from nerves becoming trapped in scar tissue or from
other causes after skin graft surgery.

Buried surgical staples / sutures- Sutures and staples used to hold skin grafts in place can
potentially become buried under the skin during healing. Additional surgery may be necessary to
remove buried staples and sutures.

Lack of graft durability- Skin grafts do not have the normal padding and durability of normal,
undamaged skin. Skin grafts lack the normal ability of skin to resist ordinary abrasions and injuries.


ADDITIONAL SURGERY NECESSARY
Should complications occur, additional surgery or other treatments may be necessary. Even though
risks and complications occur infrequently, the risks cited are particularly associated with skin graft
surgery. Other complications and risks can occur but are even more uncommon. The practice of
medicine and surgery is not an exact science. Although good results are expected, there is no
guarantee or warranty expressed or implied on the results that may be obtained.


FINANCIAL RESPONSIBILITIES
The cost of surgery involves several charges for the services provided. The total includes fees charged
by your doctor, the cost of surgical supplies, anesthesia, and possible outpatient hospital charges,
depending on where the surgery is performed. Additional costs may occur should complications
develop from the surgery. Secondary surgery or hospital day-surgery charges involved with
revisionary surgery would also be your responsibility. Health insurance may not completely cover the
costs of surgery and rehabilitation. You may require more rehabilitation services than your insurance
plan covers.


DISCLAIMER
Informed-consent documents are used to communicate information about the proposed surgical
treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s).
The informed-consent process attempts to define principles of risk disclosure that should generally
meet the needs of most patients in most circumstances.
However, every patient is unique and informed-consent documents should not be considered all
inclusive . Your plastic surgeon may provide you with additional or different information, which is
based on all the facts in your particular case and the state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care.
Standards of medical care are determined on the basis of all of the facts involved in an individual case
and are subject to change as scientific knowledge and technology advance and as practice patterns
evolve.
It is important that you read the above information carefully and have all of your questions
answered before signing the consent on the next page.

Page 4 of 5 Patient Initials

10-01-00 version

CONSENT FOR SURGERY / PROCEDURE or TREATMENT

1.

I hereby authorize Dr. ____________________________ and such assistants as may be selected

to perform the following procedure or treatment:
_____________________________________________________________________________
I have received the following information sheet:

2.

3.

4.

5.

6.

7.

8.

9.

INFORMED-CONSENT SKIN GRAFT SURGERY

_____________________________________________________________________________
I recognize that during the course of the operation and medical treatment or
anesthesia, unforeseen conditions may necessitate different procedures than those
above. I therefore authorize the above physician and assistants or designees to
perform such other procedures that are in the exercise of his or her professional
judgment necessary and desirable. The authority granted under this paragraph shall
include all conditions that require treatment and are not known to my physician at the
time the procedure is begun.
I consent to the administration of such anesthetics considered necessary or advisable.
I understand that all forms of anesthesia involve risk and the possibility of
complications, injury, and sometimes death.
I acknowledge that no guarantee has been given by anyone as to the results that may
be obtained.
I consent to the photographing or televising of the operation(s) or procedure(s) to be
performed, including appropriate portions of my body, for medical, scientific or
educational purposes, provided the pictures do not reveal my identity.
For purposes of advancing medical education, I consent to the admittance of observers
to the operating room.
I consent to the disposal of any tissue, medical devices or body parts which may be
removed.
I authorize the release of my Social Security number to appropriate agencies for legal
reporting and medical-device registration, if applicable.
IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND:
a.
THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN
b.
THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT
c.
THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED

I CONSENT TO THE TREATMENT OR PROCEDURE AND THE ABOVE LISTED ITEMS (1-9).
I AM SATISFIED WITH THE EXPLANATION.

______________________________________________________________________
Patient or Person Authorized to Sign for Patient

Date____________________ ____________________________________Witness

Page 5 of 5


Patient Initials


10-01-00 version