BILITREAT HOME PHOTOTHERAPY
CONSENT OF PHOTOTHERAPY PROCEDURE
I with detail below agreed to have my baby to undergo phototherapy treatment with all of the following have to be concerned:
1) I agreed to take my baby for further consultation to my doctor and willing to visit him/her as instructed for follow up.
2) I am aware the risk of following possibilities:
- excessive bilirubin above the photo level
- bilirubin level not responding well to phototherapy
- fluid and nutritional imbalance of the day
- possibly eye damage, if the eyes not shielded properly
- risk of hypothermia/ hyperthermia
3) I acknowledge that I have received practical instructions from company representative on how to operate the equipment. I understand that the effectiveness of this treatment depends on the area of skin exposed. I also have been informed about the minimum of 10 hours needed to make sure the effectiveness of this therapy.
4) I shall be liable for the cost of any losses including but not limited to lost, stolen and damage of the rented equipment during the rental period. Full compensation shall be made to the company.
5) I shall inform the company at least 1 day in advance before the collection date for a rental extension. Without sufficient notice, the company has the right to collect the equipment on the due time.