Wart Removal

This package includes three visits. On the first visit, Dr Rienstra will examine you to be sure this treatment is appropriate for you. (If not, there is no charge.) If appropriate, he will inject your wart(s) with a solution of diluted protein from the yeast Candida albicans, which is identical to that used by allergists for skin testing.

The physician or nurse will give you two repeat injections at monthly intervals if needed. In accord with the conditions and limitations below, we will refund payment for any wart that has not disappeared by the end of six months.

How it works
We inject a sterile material to stimulate your immune system to eliminate the virus that causes your wart. An anesthetic is injected with the material to reduce pain of injection. This stimulation of the immune system can sometimes cause the resolution of warts elsewhere on the body.

What if I have side-effects?
If you have a rash, call us. If you develop hives, take Benadryl® (diphenhydramine) 50 to 100 milligrams and call us immediately. If we are not available, you will need to go to the emergency department.

Insurance Billing
We cannot give a refund once your insurance has been billed. Therefore your options are to obtain an insurance billing form from us at each visit and forego the "No Cure - No Pay" proviso. There is no extra charge for this.

As an alternative, once treatment is complete and you are satisfied, we will provide you with health insurance claim forms. You can complete these and send them to your insurance company. (We do not provide billing forms for anyone on Medicare, Washington Basic Health, or similar insurance.)

How effective is this?
For those completing a series of three injections, this remedy is about 94% effective. You can learn more here.

What if this method does not work for me?
If this method does not remove one or more of the warts you wish removed, we will refund all or part of your payment as noted below. If you then wish us to use other methods to treat your warts, we can do that. We do not offer "No Cure - No Pay" service for those methods.

Requirements

· This service is only for non-pregnant patients with no immune problems (such as HIV).

· You must be over 18 years of age (or at least sixteen years old if living independently.)

· You must not have any problems with blood circulation to the area involved.

· Facial and genital warts do not qualify for this service. (We have other treatments for genital warts.)

· You must wear padding around any plantar warts (warts on the sole of the foot) to reduce pressure on the wart during treatment.

· You qualify for only 50% of the full refund if you smoke.

Agreement
I understand side effects of treatment may be:

· Itching, burning or pain during or after injection. (Moderate to severe pain occurs after injection in 3% of instances.) In addition, wart may turn black and peel (10% of time.)

· Flu-like symptoms or hives.

· Swollen lymph nodes

· Allergic reaction

I understand the Candida antigen is approved by the Federal Food and Drug Administration for allergy testing, and not for treatment of warts.

I agree that payment will be refunded only if these conditions have been met.

· I return for repeat treatments as scheduled by the clinic.

· That I return for final evaluation between 4 and 5 months of the last treatment.

· That one or more warts remain at that time.


I understand my skin lesion(s) may not be sufficiently typical of warts for Dr Rienstra to begin treatment. In that case,

_____ I wish to terminate the No Cure - No Pay procedure with no diagnosis given.

_____ I want Dr Rienstra give me his diagnosis either by inspection or by biopsy and will pay the usual office fee.

____________________________________ __________________

Print name                                                         Date

3/27/04 L