1. ______NO Sedatives (alcohol or drugs) for 24 hours before or 24 hours after appointment.
2. ______NO Stimulants (caffeine or nicotine or drugs) for 12 hours before or 12 hours after appointment.
3. ______NO herbals for 24 hours before and after your visit.
4. ______NO grapefruit juice for 48 hours before your appointment.
5. ______NO chance of pregnancy or nursing.
6. ______NO sensitivities to benzodiazepines or any other contraindications.
7. ______YOU MUST have a responsible person bring you and take you home from your appointment and stay with you at home until you’re recovered.
8. ______NO driving cars, boats, scooters, bikes, motorcycles, etc. for 12-24 hours after last dose.
9. ______NO operating hazardous devices (chain saws, snowmobiles, etc) for 24 hours after your appointment
10. ______NO heavy lifting for 24 hours after your appointment..
11. ______NO stairs until completely recovered.
12. ______NO Important decisions (no work) for 24 hours.
13. ______NO food or water for 12 hours PRIOR to appointment except for medications that are taken by patient on daily basis, unless advised not to.
14. ______DO NOT wear contact lenses the day of your appointment.
15. ______DO USE rest room at home right before leaving for your appointment with us..
16. ______DO wear comfortable clothes.
17. ______DO Ensure that your physicians have been contacted and signed off on your treatment. If there are medications that you need to abstain from the day before, the day of, or the day after your appointment, double check with your physician before starting or stopping any medications on your own.
18. ______DO remember to hydrate the remainder of the AFTER your visit.
19. ______DO TAKE your triazolam pill(s) ONE HOUR before your appointment.

 
I acknowledge that I have read and discussed all these instructions with Dr. Alfe. She has answered any questions I may have had regarding my treatment. I am aware of my responsibilities to ensure the best possible outcome and will adhere to Dr. Alfe’s recommendations.

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Patient Date (print)

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Patient Signature (print)

 
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Witness Date (print)

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Witness Signature (print)