South Florida Center Medical Questionnaire

Surgery Consent Waiver

915 Middle River Drive Suite 213, Fort Lauderdale, 33304, Florida
SURGERY INSTRUCTIONS
- Complete medical questionnaire as soon as possible, making sure to answer all questions fully and truthfully.
- Expect a mandatory Post-Op appointment the morning after your surgery. Plan your travel and hotel reservations to accommodate this appointment. Patients should stay within 20 miles of the surgery center for a minimum of 5 days following their surgery. Abdominoplasty (Tummy Tuck), Rhinoplasty, and Mommy Makeover patients should stay withing 20 miles of the surgery center for a miumum of 7 days following their surgery.
- Arrange for a caregiver to meet you at the surgery center, so that you can be safely discharged. Patients will not be allowed to leave in a taxi, uber, or other transport without a caregiver present.
- Full payment must be completed at least two (2) weeks prior to surgery. Failure to pay your balance within two weeks of the surgery date may results in cancellation or rescheduling.
- Patients should fill any prescriptions that are provided by your doctor prior to your surgery, so that you have medication ready during recovery.
- Patients must stop using nicotine for a period of four weeks prior to and following their surgery. Patients may be tested for nicotine. Positive nicotine tests may results in cancellation.
Today's Date*

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This facility is regulated pursuant to the rules of the board of medicine of the state of Florida as set forth in rule chapter 6455, f.a.c.

In the course of consulting and discussing with a certified medical professional, I may have been shown, or be shown certain brochures, pictures of actual patients or pictures on an electronic computer imaging device.

I understand that the pictures and alterations are solely for the purpose of illustration, discussion, and to improve communication with medical professionals.

I understand the outcome of any type of surgical procedure is directly related to individual characteristics and health.

I further understand and acknowledge that because of the obvious significant differences in how living tissues react to surgery, there is no relationship between the electronic images created, and my actual final result.

I certify my understanding that there is no warranty, expressed or suggested, as to my own final appearance after elective surgery relating to any pictures of actual patients that may have been shown.

I read (or have had read or translated to me) the above medical information listing and I hereby certify that the information I have provided above is correct and to the best of my knowledge true.

I hereby authorize the release of all my information necessary to secure payment.
I agree
Today's Date:*

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REFUND & CANCELLATION POLICY

Preparing for surgery at the South Florida Center for Cosmetic Surgery requires the resources of our medical staff, patient coordinators, and physicians. In addition, leading up to surgery, the time of our surgeons, anesthesiologists, and various support medical staff will be reserved. In the case of a cancellation, these professionals are still compensated, representing a significant loss for the South Florida Center for Cosmetic Surgery. Late cancellations can also mean that materials and instruments that have been ordered or prepared for a case go unused. To reflect this reality, we have the following cancellation policy in place. The cancellation and refund policies included below only apply to surgeries. scheduled in the future. Patients who have undergone surgery are not eligible for refund.

Cancellation Policy & Fees
- All deposits are non-refundable.
- Cancellation 15–21 days prior to your procedure date result in a 25% loss of all fees
- Cancellation 8 – 14 days prior to your procedure date result in a 35% loss of all fees
- Cancellation 7 days or less from your procedure date result in 50% loss of all fees
- Cancellation 2 days or less from your procedure date result in 100% loss of all fees
Patient Credit and Forfeiture of Payments

Deposits and payments collected by the South Florida Center for Cosmetic Surgery remain as a credit for patients to use towards surgical or non-surgical services for a period of twelve (12) months from the date of deposit. After a period of twelve (12) months, any unused monies paid to the South Florida Center for Cosmetic Surgery shall be deemed forfeited and ineligible for refund.

Surgery Payment

Payment for surgery (which includes any and all facility fees, surgeon’s fees, procedure fees, anesthesia fees and any other fees that might be involved) must be received in full two (2) weeks prior to surgery date. Scheduled surgeries that have a balance remaining within two weeks of their scheduled date are subject to be taken off the schedule or rescheduled to a later date. In these cases, full payment may be required to secure a new surgery date.

Rescheduling Policy

Any surgery rescheduled by a patient within two (2) weeks of their scheduled surgery date, will incur a $1,000 rescheduling fee. This fee will be added to the total due prior to surgery which must be paid two (2) weeks prior to surgery. The South Florida Center for Cosmetic Surgery reserves the right to reschedule surgeries leading up to the surgery date. In these rare instances, patients will be informed of these changes ahead of their surgery. Changes in scheduling do not entitled patients to a refund outside of the refund and cancellation terms.

Non-Eligible Patient Refunds

In the event a patient is deemed not a candidate for surgery with the South Florida Center for Cosmetic Surgery, they may be eligible for a partial refund, less the fees below:
- $500, all deposits are non-refundable
- Additional $250, if a medical interview/evaluation has been completed.
- Additional $250, if lab-work has been completed.
- Additional $250, if a pre-op appointment has been completed.
- Cancellation Fee, determined by time of cancellation.
Refund Processing

Refund requests must be submitted via email to refundrequest@floridacenter.com. All refund requests are reviewed by management for approval. This process can take 7-14 days. In the case that management approves a refund request, refunds will be processed with 30 days of their approval by South Florida Center for Cosmetic Surgery. All refunds will be made to the original payment method. Cash and Cashier’s Checks will be refunded by mailed check.
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Today's Date*

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HIPAA PRIVACY NOTICE

THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY.

• Your confidential healthcare information may be released to other healthcare
professionals within the organization for the purpose of providing you with quality healthcare.

• Your confidential healthcare information may be released to your insurance provider for the purpose of the organization receiving payment for providing you with needed healthcare services.

• Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence.

• Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care.

• Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).

• Your confidential healthcare information may be released for any other purpose than that which is identified in this notice.

• Your confidential healthcare information may be released only after receiving written authorization from you. You may revoke your permission to release confidential healthcare information at any time.

• You may be contacted by the organization to remind you of any appointments, healthcare treatment options or other health services that may be of interest to you.

• You may be contacted by the organization for the purposes of raising funds to support the organization's operations.

• You have the right to restrict the use of your confidential healthcare information. However, the organization may choose to refuse your restriction if it is in a conflict of providing you with quality healthcare or in the event of an emergency situation.

• You have the right to receive confidential communication about your health status.

• You have the right to review and photocopy any/all portions of your healthcare information.

• You have the right to make changes to your healthcare information.

• You have the right to know who has accessed your confidential healthcare information and for what purpose.

• You have the right to possess a copy of this Privacy Notice upon request. This copy can be in the form of electronic transmission or on paper.

• The organization is required by law to protect the privacy of its patients. It will keep confidential any and all patient healthcare information and will provide patients with a list of duties or practices that protect confidential healthcare information.

• The organization will abide by the terms of this notice. The organization reserves the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information. Patients will receive a mailed copy of any changes to this notice within 60 days of making the changes.

• You have the right to complain to the organization if you believe your rights to privacy have been violated. If you feel your privacy rights have been violated, please mail your complaint to the organization:
South Florida Center for Cosmetic Surgery
ATTN: Privacy Rights Claim
915 Middle River Drive, 2nd Floor
Fort Lauderdale, Florida 33304

• All complaints will be investigated. No personal issue will be raised for filing a complaint with the organization.

▪ For further information about this Privacy Notice, please contact administrator at (954) 565 - 7575.

▪ This notice is effective as of Date of Effectiveness. This date must not be earlier than the date on which the notice is printed or published.
I Agree
Date*

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PATIENT HIPAA ACKNOWLEDGEMENT AND DESIGNATION DISCLOSURE FORM

I. Acknowledgment of Practice's HIPAA Privacy Notice:

By signing my name below, I acknowledge that South Florida Center for Cosmetic Surgery has provided a copy of the HIPAA Privacy Notice and that I have read (or had the opportunity to read if I so chose) and understand my rights and ask questions regarding my rights and receive answers to my satisfaction; and agree to its terms.

II. Designation of Certain Relatives, Close Friends, and other Caregivers as my Personal Representative: I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing since such person is involved with my health care or payment relating to my health care. In that case, the Physician Practice will disclose only information that is directly relevant to the person's involvement with my health care or payment relating to my health care.
I Agree
Signature*

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Date*

MonthDayYear
Date
Patient's Name *

First NameMiddle NameLast Name
Phone Number *

Area CodePhone Number
By entering in my mobile number above, I authorize South Florida Center For Cosmetic Surgery to send me text messages regarding my account and about their appointments, services, and promotions using an automatic telephone dialing system. I understand that I am not required to choose "Yes" as a condition of purchasing any service. (If I receive a text message, I can reply HELP for help or reply STOP to withdraw consent. Message and data rates may apply.) *

YesNo
Patient's Date of Birth *

MonthDayYear
Date
I Agree
Request to Receive Confidential Communications by Alternative Means: As provided by Privacy Rule Section 164.522(b), I hereby request that the Practice make all communications to me by :

PhoneEmailFax
If unanswered we should *

Leave a message with detailed informationLeave a message with a call back number
Patient's Signature

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Gender *

MaleFemaleTransgender Male to FemaleTransgender Female to Male
Age *
Height
Weight in lbs.
Patient's Address*

Street Address, P.O box

Apartment, Suite, Unit, Building, Floor, Etc.

CityState / Province

Postal / Zip Code
Email Address *
example@example.com
Confirm Email *
example@example.com
Emergency Contact
Emergency Contact's Name *

First NameLast Name
Emergency Contact's Phone Number *

Area CodePhone Number
Patient's Driver's License / ID Card
Driver's License/ID Card Number*
Issuing State *
Issuing State*
Medical History
Allergies to any medication:
Do you take medications?*

Noyes
If yes, list all medications, reactions, vitamins, diet pills or herbal supplements:
List all prior surgeries and dates (example, c-section, appendectomy, liposuction):
Are you a previous patient of the South Florida Center for Cosmetic Surgery?*

NoYes
Have you had tubal ligation or hysterectomy?*

Noyes
Have you had a termination of pregnancy, or miscarriage in the last 3 months?*

NoYes
Have you ever had anesthesia?*

NoYes
If yes, any complications with anesthesia?

NoYes
Any history of difficult intubation?

NoYes
Any family history of life-threatening complications from anesthesia?

NoYes
If yes, list complications
Malignant Hyperthermia? *

NoYes
Prolonged wake up after surgery?*

NoYes
Post-Op Nausea / Vomiting?*

NoYes
Excessive sore throat? *

NoYes
Prolonged Paralysis? *

NoYes
If yes to any complications, please describe:
Any family history of life-threatening complications from Anesthesia? *

NoYes
If yes, list:
Do you have COPD (Chronic Obstructive Pulmonary Disease)?*

NoYes
Have you had lung surgery?*

NoYes
Do you have high blood pressure?*

NoYes
Have you ever had a heart attack?*

NoYes
Do you have cardiac stents?*

NoYes
Do you have a pace maker?*

NoYes
Do you have heart disease or have undergone heart surgery?*

NoYes
Do you have any history of a stroke or TIA?*

NoYes
Have you had brain surgery?*

NoYes
Do you have any blood or clotting disorder?*

NoYes
Do you have any history of having a pulmonary embolism?*

NoYes
Do you have any history of having a DVT (Deep Vein Thrombosis)?*

NoYes
Do you have sickle cell disease?*

NoYes
Do you have any history of Hepatitis?*

NoYes
Do you have chronic bronchitis?*

NoYes
Do you have any history of cancer?*

NoYes
Do you have any family history of breast cancer?*

NoYes
If applicable when was your last mammogram?

MonthDayYear
Date
Do you smoke or use nicotine?*

NoYes
If yes, how often

DailyFew times a weekOther
Do you vape?

NoYes
Have you ever regularly smoked, vaped, or used nicotine in the past?

NoYes
Do you drink? *

NoYes
If yes, how often?

DailyWeeklySocially
Do you take recreational drugs? *

NoYes
If yes, what type and how often?
Do you take Steroids? *

NoYes
If yes, list:
Do you have any loose teeth, dentures, chipped teeth, or veneers? *

NoYes
If yes, list:
PLEASE MARK ANY OF THE FOLLOWING CONDITIONS THAT YOU HAVE OR HAVE HAD IN THE PAST:
CARDIOVASCULAR:
1. Do you Exercise? *

NoYes
If yes, how often and type of exercise:

Strenuous exerciseModerate exerciseLight exercise
High Blood PressureMI/Heart DiseaseDeep Vein ThrombosisHeart MurmurBleeding/Clotting DisorderPulmonary EmbolismIrregular HeartbeatCongestive Heart FailurePacemakerDysrhythmiaValve Disease (mitral valve prolapse)Cholesterol diseaseSickle Cell AnemiaEnlarged HeartBlood ClotSickle Cell Trait
2. Do you experience Shortness of Breath or heart palpitations during exercise? *

NoYes
Do you have any of the following symptoms?

Chest pain/AnginaShortness of BreathLightheadednessPalpitationsExtremity NumbnessExcessive bleeding/bruising
RESPIRATORY:

Shortness of BreathChronic BronchitisEmphysemaWheezingLung CancerChronic Obstructive Pulmonary Disease (COPD)
Do you have Asthma? *

NoYes
If Yes, Do you use an inhaler?

NoYes
How often?
Name of Inhaler
Date of last Asthma attack

MonthDayYear
Date
Were you hospitalized?

NoYes
Do you have Sleep Apnea? *

NoYes
If yes, do you use a CPAP machine?

NoYes
Do you have any of the following symptoms?

Air HungerCough (Dry or Productive)Shortness of BreathWheezingSleeplessness
Do you snore? *

NoYes
If yes, please check if you have the following symptoms:

Check here if you snore loudly (loud enough to be hard through closed doors of your bed partner elbows you for snoring at night)Check here if you often feel tired, fatigued, or sleepy, during the daytime (such as falling asleep during driving or talking to someone)Check here if anyone has observed you stop breathing or choking/gasping during your sleepCheck here if you have or are being treated for High Blood PressureCheck here if your body mass index is more than 35 kg/m²Check here if you are 50 years or olderCheck here if your neck collar is 17 inches or more (male) or if your neck collar is 16 inches or more (female)Check here if you are male
If you answered yes, to any question, please give more details on condition and if any current or previous treatment.
Have you tested positive for COVID-19 in the last 12 months?

NoYes
If Yes, when was the date of your last positive test?

MonthDayYear
Date
If you've had COVID-19, which symptoms did you experience?
PLEASE MARK ANY OF THE FOLLOWING CONDITIONS THAT YOU HAVE OR HAVE HAD IN THE PAST
GASTROINTESTINAL / ENDOCRINE / RENAL:

Reflux/GERDUlcersCirrhosisFatty LiverHepatitis B/CJaundiceLiver DiseaseChronic CystitisRenal FailureRenal InsufficiencyDialysisBladder Cancer
Do you have Diabetes? *

NoYes
If yes, which type?

Childhood OnsetAdult Onset
Do you take Insulin? *

NoYes
Do you have Thyroid disease? *

NoYes
If yes, which type?

HighLow
Do you have any of the following symptoms?

HeartburnUrinary RetentionWeight LossConstipationNauseaPainful UrinationDiarrheaVomitingFrequent UrinationDepressionJaundiceAnxietyExcessive FatiguePruritusExcessive SweatingCold IntoleranceExcessive ThirstHeat IntoleranceWeight Gain
NEUROVASCULAR / NEUROMUSCULAR:

CVA/TIAStrokeMyasthenia GravisNerve DamageParkinson's DiseaseBrain CancerMigrainesMalignant HyperthermiaBrain StentNeuropathyGlaucomaMyopathyADD/ADHD
Do you have Seizures / Epilepsy? *

NoYes
If yes, date of last seizure

MonthDayYear
Date
Do you have Multiple Sclerosis? *

NoYes
Do you have any of the following symptoms?

ParalysisMuscle WeaknessVertigoDouble VisionUnbalancedTremors
Do you have HIV? *

NoYes
If yes, do you take medication?

NoYes
Is there any medical condition or symptom that you need to discuss with the nurse? *

NoYes
List any syndrome or medical condition that you have, that was not listed on this form
Electronic Signature Consent *

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such a copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
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Surgery Consent Waiver