1. You have received: ¹⁰³Palladium ___________ ¹²⁵Iodine ____________

2. You may resume same diet as prior to admission.

3. Take any medication ordered by your physician as directed.

4. Though exposure of family members/friends to radiation is very unlikely, there are a few precautions you do need to take.
   1. You must urinate through a special screen, which will be given to your before discharge. You must use the screen for two weeks after the procedure. If you see a seed in your urine or semen, place it in the specimen container provided with a lid on the top and bring it to the Nuclear Medicine Department in Radiology at Reston Hospital Center. If a seed gets stuck in the screen, you may use a pair of tweezers or a tongue blade to remove it from the screen and place it on the container. DO NOT touch the seed with your hands!
   2. Wear a condom for intercourse for two months after the procedure.
   3. Do not let anyone sit on your lap for two months after the procedure, particularly children and pregnant women.

5. If you find a seed in your urine or semen, call the Radiology Department at (703) 689-9007 between 8:00 a.m. and 5:00 p.m. and report it to the Nuclear Medicine Department. It is not an emergency, so it is not necessary to call the Radiology Department in the middle of the night with this information.

6. If you should have an MRI for any reason, you should tell the technician prior to the MRI that you have received this radiation implant treatment.

7. After this procedure, there is an increased risk of rectal ulceration/bleeding a few weeks to 1-2 years later. If this should happen, it is critical you follow the instructions below:
   1. Contact your Radiation Oncologist as well as your Urologist.
   2. Avoid laser treatment, coagulation, or rectal surgery, including hemorrhoidectomy or repair of anal fissures. Painful rectal ulcers or fistulas may result.

      SEVERE COMPLICATIONS THAT MAY REQUIRE A COLOSTOMY MAY RESULT FROM ANY OF THE TREATMENTS LISTED IN #7.

8. Please present these instructions to your Gastroenterologist or surgeon prior to a sigmoidoscopy or colonoscopy.

Patient Signature:_____________________________ Date:_________________________

Witness Signature:_____________________________ Date:_________________________