PROCEDURES PERFORMED
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1 PROCEDURES PERFORMED Dr. Rehnke regularly performs each of the surgical procedures listed here. You can be confident that the doctor is experienced and specially trained in each one. Our office staff is also knowledgeable about these procedures and will be able to give you thorough information to help you understand the benefits as well as risks of each one. BREAST COSMETIC Breast Augmentation with Autologous Fat Grafting & Internal Mastopexy Breast Enlargement Breast Enlargement without Breast Implants [Autologous Fat Grafting] Breast Enlargement with Implants [Endoscopic Augmentation] Breast Enlargement with Implants [Subglandular Augmentation] Breast Enlargement with Implants [Submuscular Augmentation] Breast Lift [with Internal Mastopexy] Breast Lift [Concentric Mastopexy] Breast Lift [Standard Mastopexy] Removal & Replacement of Breast Implants [Explanation of Breast Prosthesis with Secondary Augmentation Mammoplasty] Removal of Breast Implants with Internal Mastopexy and Fat Grafting Male Breast Reduction [Reduction of Gynecomastia] BREAST RECONSTRUCTIVE Biopsy or Removal of Breast Lump [Breast Biopsy or Lumpectomy] Reconstructive Breast Surgery Without Breast Implants [Autologous Fat Grafting] Breast Reconstruction Latissimus [Latissimus Dorsi Myocutaneous Flap] Breast Reconstruction with Implant Breast Reduction [Reduction Mammaplasty] Nipple Reconstruction [Nipple-Areolar Complex Reconstruction] Removal of Breast Implants [Capsulectomy with Explanation of Breast Prosthesis] Removal of Breast Tissue [Subcutaneous Mastectomy] Revision of Breast Enlargement [Capsulectomy (Subglandular Reaugmentation)] Revision of Breast Enlargement [Capsulectomy (Subpectoral Reaugmentation)] BODY CONTOURING Lifting Thighs and Removal of Abdominal Skin [Lower Body Lift] Liposuction [Suction Assisted Lipectomy] Thigh-Buttock Lift [Thighplasty] Tummy Tuck [Abdominoplasty] Upper Arm Lift [Brachioplasty]
2 FACIAL PROCEDURES PERFORMED Chin Enlargement [with Fat Grafting] Eyelid Lift [Blepharoplasty] Facelift [Rhytidectomy] Forehead Lift [Direct Brow lift] Forehead Lift [Endoscopic Brow lift] Lower Eyelid Lift [Trans-Conjunctival Blepharoplasty] Lower Eyelid Suspension [Canthopexy] Midface Lift Neck Lift [Submental Lipectomy] Fat Grafting Nano Fat Grafting to Deep Dermis EARS Ear Pinning [Otoplasty] SKIN & SCARS Reconstructive Skin Repair [Skin Flaps] Removal of Skin Lesions [Excision of Skin Tumors and Cysts] Scar Repair Using Z-Plasty Technique [Z-Plasty Scar Revision]
3 PLEASE VISIT DAYGLO MED-SPA Dr. Robert Rehnke and DayGlo Med-Spa are proud to offer corrective, advanced medical skin care that utilizes the most progressive treatments and products. SERVICES PROVIDED BY OUR NURSE PRACTITIONERS FILLERS AND INJECTABLES Juvederm Voluma Botox Volbella Kybella Xeomin Belotero Radiesse Restylanne Silk NON-SURGICAL FACIAL REJUVENATION Kybella PDO Threads MICRONEEDLING WITH RF (RADIO FREQUENCY) Lutronic - INFINI
4 O V E R V I E W * REGISTRATION SURGEON CONFERENCE We request basic information for our administrative records and provide you with an overview of the consultation process. The fee for consultation is $ We accept cash, check, MasterCard, Visa, American Express and Discover. Dr. Rehnke will talk with you about your wishes and desires. He will examine you and give you his opinion about how to achieve your goals. We believe you need to be well-informed about the actual process of preparing for, and recovering from, cosmetic or reconstructive surgery. Choosing a surgeon is an intensely personal decision. We encourage you to take time to ask the doctor and his staff any questions you may have. We believe the formation of a personal bond is an integral part of the surgery and healing process. COST/TIMING ANESTHESIA FOLLOW UP CERTIFICATION When you briefly meet with the Patient Coordinator, she will discuss fees and costs. The consultation fee will be collected at this time. If you have a specific date in mind, we will do our best to accommodate your schedule. If you are still in the information gathering phase, she will try to be sure all of your questions are answered. Prior to surgery, you will have an opportunity to discuss your concerns and wishes with your Anesthesiologist. After your procedure, you will be seen for a follow up appointment. At that time, please feel free to ask any further questions you may have for Dr. Rehnke or the members of our staff. Dr. Rehnke is board certified in Plastic Surgery. Our Operating Room is also certified by the American Association for Accredidation of Ambulatory Surgery Facilities (AAAASF). All professional staff are ACLS certified. Robert D. Rehnke, M.D., F.A.C.S (727)
5 patient information form. Board certified by both the American Board of Plastic Surgery and the American Board of Surgeons p ! th Avenue N., St. Petersburg, FL 33710! Name: Date: Address: Date of Birth: City: State: Zip: Cell Phone: Social Security No.: Home Phone: Indicate Best Phone: Cell Home Name of Family Physician: Family Doctor Ph: Contact in Case of Emergency: Emergency Ph: Employer: Would you like to receive notifications/reminders of appts via (check all that apply): Text Phone Marital Status: Single Married Widowed Divorced Separated Sex: Male Female Reason for Visit: Breast Augmentation Breast Reduction Facial Rejuvenation: Forehead Face Eyes Body Contouring: Abdomen Hips/Legs Arms Fat Transfer (indicate where): Other: How were you referred to Dr. Rehnke? Physician s Name: Website Name: Friend s Name: Other: Insurance Information: is required and kept on file for emergency purposes, even if your procedure is not covered by insurance. Insurance Carrier: Address: Telephone Number: Policy Number: Group Number: Insured Name: Consent for Treatment: I, undersigned, hereby consent to and authorize all diagnostic and therapeutic considered or advisable in the judgment of the attending physician. Authorization to Release Information: I authorize the release of any medical information to process my health insurance claim form, if applicable. Signature: Date:
6 patient history form. Name: Chief complaint or reason for visit: PRESENT ILLNESSES (i.e. high blood pressure, diabetes, sleep apnea restless legs, bleeding problems, GERD, glaucoma, etc.) Date Onset HOSPITALIZATIONS Date Reason KNOWN ALLERGIES (food/meds) And Reaction PREVIOUS SURGERY Yes No Breast. If yes, why? Hysterectomy. If yes, why? Tonsils Appendix Gall Bladder Hernia Tubal Ligation Caesarean Section D & C Eyes, Ears, Nose, Throat Skin Cancer Other PRESENT M EDICATION & dose FAMILY HISTORY Blood Clots Thyroid Disease Diabetes Tuberculosis Breast Cancer Cancer Epilepsy Heart Disease High Blood Pressure Glaucoma Malignant Hyperthermia Other PAST ILLNESSES Yes No Tuberculosis Cancer Epilepsy Rheumatic Fever German Measles Jaundice Blood Clot High Blood Pressure Anemia Blood Disease Sleep Apnea Asthma Severe Cramps, Menses Freq. Vaginal Infection Freq. Bladder Infection Peptic Ulcer Gout Alcohol Heart Disease Arthritis Stroke Diabetes Bleeding Tendencies Other SOCIAL H ABITS Drinking Alcohol (current) (past) Aspirin Coffee Tea Smoking (current) (past) How much/frequency FEMALE O NLY No. of Pregnancies Living Children Last Delivery Menses Regular Irregular Last Period Last PAP Smear Last Mammogram
7 Patient HIPAA Consent Form The Department of Health and Human Services has established a Privacy Rule to help insure that personal information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient we want you to know that we respect the privacy of your personal medical and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect that privacy. When it is appropriate and necessary, we provide the minimum necessary information about treatment, payment or health care operations, in order to provide health care that is in your best interest. We are required to notify you if your PHI is ever breached. We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of our personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form or have complaints about violations of your privacy rights please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice. This office is regulated pursuant to the rules of the Board of Medicine as set forth in Rule Chapter 64B8, F.A.C. Print Name Signature Date
8 D I R E C T I O N S From Tampa: th Avenue North St. Petersburg, FL (727) Take I-275 south over the Howard Franklin Bridge to exit 25 (38th Avenue North). Exit at 38th Avenue North and go west to 66th Street North (approximately 3 miles). Turn left onto 66th Street and take 66th Street down to 10th Avenue North. Make a right on 10th Avenue North and your first left into our parking lot. We are located on the corner of 66th Street North and 10th Avenue North. From Bradenton / Sarasota: Take I-275 north over the Sunshine Skyway Bridge to exit 24 (22nd Avenue North). Exit at 22nd Avenue North and go west to 66th Street (approximately 3.5 miles). Turn left onto 66th Street North and take 66th Street down to 10th Avenue North. Make a right on 10th Avenue North and your first left into our parking lot. We are located on the corner of 66th Street North and 10th Avenue North. From Clearwater: Take Route 19 South to 22nd Avenue North. Make a right onto 22nd Avenue North and take 22nd Avenue to 66th Street North. Turn left onto 66th Street North and take 66th Street down to 10th Avenue North. Make a right on 10th Avenue North and your first left into our parking lot. We are located on the corner of 66th Street North and 10th Avenue North.
SYNERGY PLASTIC SURGERY
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Associated Plastic Surgeons, S.C. Otto J. Placik, M.D., F.A.C.S.
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May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female
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NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning
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ObGyne Consultants ObGyne After Hours Middle Georgia Immediate Care Center
1 ObGyne Consultants ObGyne After Hours Middle Georgia Immediate Care Center http://obgyneconsultants.com http://obgynepatientnews.com Macon 639 Hemlock St. Macon, GA 31201 P: (478) 745-3014 F: (478) 745-9887
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Male Female Mailing Address: Apt. #: City: State: Zip Code:
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2014 575 Hill Country Dr. Ste 202 Kerrville, TX 78028 (830)258-6237 Office (830)315-1366 Fax Patient Name (last, first, MI) of Birth Social Security Number Mailing Address Home Telephone Work Telephone
NAME SS# ADDRESS CITY STATE ZIP. TELEPHONE (home) (business) Cell SEX M F BIRTH DATE PLACE OFBIRTH RACE ETHNICITY LANGUAGE
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PATIENT WILL NOT BE SEEN WITHOUT PHOTO ID Patient Information Kimberly Walpert, M.D. 1199 Prince Avenue Athens GA 30606 Ph 706-475-1870 Fax 706-475-1879 www.athensbrainandspine.com Patient Name First Middle
date of birth: age: gender: n f n m marital status: n m n s n d n w profession: employer: reason for consultation: referred by:
grossman plastic surgery john a. grossman, m.d. philippe a. capraro, m.d. 4600 hale parkway suite 100 denver, colorado 80220 phone: 303-320-5566 or 800-394-0010 fax: 303-320-1453 patient information date:
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City. Whom may we thank for referring you to us?
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Ivis M. Getz, D.M.D. Caring For Kids Pediatric Dentistry, P.C. 140 Lockwood Avenue, Suite 315, New Rochelle, NY 10801
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We must have ALL paperwork least 72 hrs prior to your appointment, Thanks.
Thomas A. Lombardo, MD T. Randolph Lombardo, MD Jorge A. Hernandez, MD Alfred B. Brady, MD Mark Fasulo, MD Allen D. McGrew, DO, FACC Sheila DeVaugh, APRN, BC Greg Gilbreath, APRN, BC Amanda J. Reneau,
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Patient Demographic Sheet
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