Surgical Consents General with Breast Implants

Surgical Consents
Smokers' Acknowledgement
Dr. Farahmand has informed me of the significantly increased risk of wound healing and infectious complications associated with smoking. I have been advised by Dr. Farahmand to discontinue completely all nicotine products including cigarettes, vape pens, vapers, hookah, nicotine gums, tablets, and patches for a full two months prior to surgery and one month after surgery. I understand that doing this will improve my outcome but does not warranty or guarantee that any complications will not occur. Also, Dr. Farahmand has informed me that my exposure to second hand smoke will also increase my chances of complications and that I should also be away from second hand smoke for a full two months before surgery and also a month after surgery.
Patient Signature. Sign full Signature with finger or mouse*
Date*

MonthDayYear
Date
Illicit/Illegal Drugs and Surgery Warning
WARNING: If you have used or are planning to use illicit/illegal drugs within 72 hours of your surgical procedure, it could severely interfere with your anesthesia. It could cause a wide range of medical and surgical complications. The drug using patient having surgery needs special attention in order to avoid interactions and complications. Please speak to Dr. Farahmand about your drug use so that she may review different drugs and their clinical effects and the problems which could be encountered. If you have used illicit/illegal drugs 72 hours prior to your surgery it is recommended that you reschedule your surgery to another date.
Patient Signature/Date: Sign full Signature with finger or mouse *
Date*

MonthDayYear
Date
Surgical Cost Information
Our goal is to give each and every patient the best results. Unfortunately approximately 5% of all Plastic Surgery procedures will require revision(s) due to excess scar tissue.

Should this apply, our policy is to only charge for facility costs and anesthesia. The charge will be approximately $2,200.00. You will not be charged for doctor's time. This revision policy above is applicable to scar tissue only for breast augmentations. Not included are deflations or changing the size of implants.
Patient Signature. Sign full Signature with finger or mouse*
Date*

MonthDayYear
Date
Hospital Privileges
I have been notified that Dr. Audrey Farahmand has privileges to perform all of the same procedures as those performed under anesthesia in our facility with Lee Health. This includes the following hospitals; Gulf Coast Hospital, Health Park, Lee Memorial Hospital and Cape Coral Hospital.
Patient's Signature. Sign full Signature with finger or mouse*
Date*

MonthDayYear
Date
Post-Operative Care Appointments
I have been notified If Dr. Audrey Farahmand is unavailable to provide post-operative care during my four weeks post-operative period she has coverage pre-arranged with a Board Certified Plastic Surgeon.
Patient's Signature. Sign full Signature with finger or mouse*
Date*

MonthDayYear
Date
Pump Consignment Form
Name*

First NameLast Name
For patients sent home with a pump after surgery.

(patient name) understand that this device is on a complimentary loan to me from Farahmand Plastic Surgery. This device is to be used by

me for the first 72 hours post-operative period. I agree to be responsible for any damages or loss of the equipment while it is in my care.
I attest that I received the educational pamphlet “Information on Nonopioid Alternatives for the Treatment of Pain”, pursuing to Florida House Bill 451. This pamphlet is intended to provide information regarding nonopiod alternatives to treat pain. I understand that I must ask Dr. Farahmand and/or Staff for approval before taking any medications or starting any alternative treatment plans that were not prescribed or discussed with Dr. Farahmand. By signing below I acknowledge that I received the pamphlet “Information on Nonopioid Alternatives for the Treatment of Pain”.
Patient's Signature. Sign full Signature with finger or mouse*
Date*

MonthDayYear
Date
Narcotic Alternatives

I attest that I received the educational pamphlet “Information on Nonopioid Alternatives for the Treatment of Pain”, pursuing to Florida House Bill 451. This pamphlet is intended to provide information regarding nonopiod alternatives to treat pain. I understand that I must ask Dr. Farahmand and/or Staff for approval before taking any medications or starting any alternative treatment plans that were not prescribed or discussed with Dr. Farahmand. By signing below I acknowledge that I received the pamphlet “Information on Nonopioid Alternatives for the Treatment of Pain”.
Patient's Signature. Sign full Signature with finger or mouse *
Date*

MonthDayYear
Date
Name*

First NameLast Name
Pregnancy Waiver for Surgical Procedure
I understand that anesthesia and

surgery can potentially cause harm to an unborn fetus (including but not limited to birth defects and/or miscarriage I further understand that pregnancy testing is not 100% accurate and that I could still be pregnant even with a negative test. I also understand that I could become pregnant between the time of my test and the date of surgery. I hereby certify that I am not pregnant and I voluntarily release Dr. Audrey Farahmand and any other person, and his/her agents,

employees, heirs and assigns from any and all claims, known or unknown, anticipated or unanticipated, or damages relating to the unborn fetus or to me, should I be pregnant, arising out of the administration of anesthesia, the performance of surgery, and/or the performance of any other treatment or administration of medication that may be required while under Dr. Audrey Farahmand’s care.
Name*

First NameLast Name
I also choose to waive a serum pregnancy test. I am positive I am not pregnant at this time.*
pregnancy test. I am positive I am not pregnant at this time.
Surgery Date:*

MonthDayYear
Date
I also choose to waive a serum pregnancy test. I am positive I am not pregnant at this time. Patient's Signature. Sign Full Signature with finger or mouse*
Date*

MonthDayYear
Date
Breast Augmentation Warranty
I have been informed of the Mentor Enhanced Advantage Limited Warranty. I understand that, should I elect to purchase, I must do so within 30 days of my qualifying implantation. I also understand the steps necessary to purchase the program as outlined in The Mentor Advantage Limited Warranty brochure.
Patient's Signature. Sign Full Signature with finger or mouse*
Date*

MonthDayYear
Date
Mentor Silicone Implant Acknowledgement Informed Decision
I understand that this patient brochure, "Important information for Augmentation Patients About Mentor MemoryGelTM Silicone Gel-Filled Breast Implants", is intended to provide the information regarding the risks and benefits of silicone gel-filled breast implants, both general and specific to Mentor's MemoryGel products. I understand that silicone breast implant surgery involves risks and benefits, as described in this brochure. I also understand that the long-term (i.e. 10-year) safety and effectiveness of silicone gel-filled breast implants continue to be studied. I understand that reading and fully understanding this brochure is required, but that there also must be consultation with my surgeon.
I have had adequate time to read and fully understand this brochure*

Initials
Type YES or NO: I have had adequate time to read and fully understand this brochure*
I have had an opportunity to ask my surgeon any questions I may have about this brochure or any other issues related to breast implant surgery.*

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Type YES or NO. I have had an opportunity to ask my surgeon any questions I may have about this brochure or any other issues related to breast implant surgery.*
I have considered the alternatives to silicone breast implants and have decided to proceed with silicone breast implant surgery.*

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Type YES or NO: I have considered the alternatives to silicone breast implants and have decided to proceed with silicone breast implant surgery.*
I have been advised to wait an adequate amount of time after reviewing and considering this information, before scheduling my silicone breast implant surgery; and*

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Type YES or NO: I have been advised to wait an adequate amount of time after reviewing and considering this information, before scheduling my silicone breast implant surgery; and*
Type YES or NO: I will retain this brochure, and I am aware that I may also ask my surgeon for a copy of this signed acknowledgment.*
I will retain this brochure, and I am aware that I may also ask my surgeon for a copy of this signed acknowledgment.*

Initials
Patient Signature. Sign Full Signature with finger or mouse*
Date*

MonthDayYear
Date
Type Patient First and Last Name:*
*A patient must be at least 22 years old for primary and revision breast augmentation with silicone breast implants.

By my signature below, I acknowledge that:

*My patient has been given an opportunity to ask any and all questions related to this brochure, or any other issues of concern;

*All questions outlined above have been answered "YES" by the patient;

*My patient has had an adequate amount of time before making her final decision; and

*Documentation of this informed decision will be retained in my patient's permanent record.
Patient's Signature. Sign full name with finger or mouse*
Patient Print Name*
Date*

MonthDayYear
Date
Authorization for Disclosure of Protected Health information Medical Records Release
Patient Name:*
Maiden Name:
Date of Birth:*

MonthDayYear
Date
Social Security Number:*
I hereby authorize the release of my protected health information from:
Name: Farahmand Plastic Surgery
To
Name: KPOW Anesthesia
Other:
The following information may be disclosed (Choose one of the following):

***All medical Records Covering dates

***Specific Medical Records: SURGICAL PACKET AND TEST RESULTS
***Other (Specify)
***Other (Specify)
***I understand that these records may include information relating to: * Acquired immunodeficiency syndrome (AIDS)/human immunodeficiency virus (HIV); or * Sexually Transmitted Diseases; or * Behavioral health service, psychiatric care

I understand that I may revoke this authorization at any time, except to the extent that action has been taken in reliance to this authorization or, if applicable, during a contextability period. The revocation must be made by completing Farahmand Plastic Surgery's "Revocation of an Authorization to Release Protected Health information" form. I also understand that I will not be denied or refused treatment if I refuse to sign this authorization. I further understand that the information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by Federal and State privacy laws. I also understand that I have a right to receive a copy of this authorization if I request one. This authorization will expire "1" year from the date signed.
Signature of the Patient/Guardian/Legal Representative. Sign full name with finger or mouse.*
Date Signed*

MonthDayYear
Date
(If not signed by patient) Print Name*
Relationship to Patient*
Authorization for Disclosure of Protected Health information Medical Records Release
Patient Name:*
Maiden Name:
Date of Birth:*

MonthDayYear
Date
I hereby authorize the release of my protected health information from:
Name: Farahmand Plastic Surgery
To
Name: Patient (Self)
For the Purpose of: (Choose one)
Personal
Personal
Other:
Other:
The following information may be disclosed (Choose one of the following):

***All medical Records Covering dates

***Specific Medical Records: Before and After Photos
***Other (Specify)
***Other (Specify)
***I understand that these records may include information relating to: * Acquired immunodeficiency syndrome (AIDS)/human immunodeficiency virus (HIV); or * Sexually Transmitted Diseases; or * Behavioral health service, psychiatric care

I understand that I may revoke this authorization at any time, except to the extent that action has been taken in reliance to this authorization or, if applicable, during a contextability period. The revocation must be made by completing Farahmand Plastic Surgery's "Revocation of an Authorization to Release Protected Health information" form. I also understand that I will not be denied or refused treatment if I refuse to sign this authorization. I further understand that the information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by Federal and State privacy laws. I also understand that I have a right to receive a copy of this authorization if I request one. This authorization will expire "1" year from the date signed.
Signature of the Patient/Guardian/Legal Representative*
Date Signed*

MonthDayYear
Date
(If not signed by patient) Print Name*
Relationship to Patient*
FARAHMAND PLASTIC SURGERY COVID-19 RISK INFORMED CONSENT
I, Type First and Last Name*
patient's name
(patient name) understand that I am opting for an elective

treatment/procedure/surgery that is not urgent and may not be medically necessary.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Dr. Audrey Farahmand and all the staff at Farahmand Plastic Surgery (practice name) are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment/procedure/surgery, and I give my express permission for Dr. Audrey Farahmand and all the staff at Farahmand Plastic Surgery (practice name) to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, and possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure/surgery itself.

I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery.

I understand that I need to Self-isolate between the time of my testing and date of surgery.
Patient or Person Authorized Signature Date/Time
I UNDERSTAND THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE. Sign full signature with finger or mouse.*

Patient or Authorized person Signature
Date*

MonthDayYear
Date
I have been offered a copy of this consent form patient’s initials. Type your initials*
Initials
©2020American Society of Plastic Surgeons®.Purchasers of the Informed Consent Resourceare given a limited license to modify documents contained herein and reproduce the modified version for use in the Purchaser's own practice only.All other rights are reserved by the American Society of Plastic Surgeons®.Purchasers may not sell or allow any other party to use any version of the Informed Consent Resource,any of the documents contained herein,or any modified version of such documents.Refer to you state laws regarding telemedicine/telehealth rules
Farahmand Plastic Surgery
Authorization for Disclosure of Protected Health Information Medical Records Release * Optional

To be filled out only if you would like us to request your medical records from another doctor or facility
Name*

First NameLast Name
Patient Name:
Maiden Name:
Date of Birth*

MonthDayYear
Date
I hereby authorize the release of my protected health information from(name of doctor or facility you want us to request your records from) optional:
Phone of that doctor or facility
Personal
Insurance
Other:
The following information may be disclosed (Choose one of the following):
All Medical Records Covering dates
All Medical Records Covering dates

MonthDayYear
Date
through
Specific Medical Records
I understand that these records may include information relating to:

*Acquired immunodeficiency syndrome (AIDS) / human immunodeficiency virus (HIV); or *Sexually Transmitted Diseases; or *Treatment for alcohol and/or drug abuse; or *Behavioral health service / psychiatric care

I understand that I may revoke this authorization at any time, except to the extent that action has been taken in reliance o this authorization or, if applicable, during a contestability period. The revocation must be made by completing Farahmand Plastic Surgery’s “Revocation of an Authorization to Release Protected Health Information” form. I also understand that I will not be denied or refused treatment if I refuse to sign this authorization. I further understand that the information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer protected by Federal and State privacy laws. I also understand that I have a right to receive a copy of this authorization if I request one. This authorization will expire “1” year from the date signed.
Signature of the Patient/Guardian/Legal Representative
Date Signed

MonthDayYear
Date
(If not signed by patient) Print Name
Relationship to Patient
TELEHEALTH INFORMED CONSENT
Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format. Sign Your Initials with finger or mouse*

Initial
I understand that I may opt out of the telehealth visit at any time. This will not change my ability to receive future care at this office. Sign Your Initials with finger or mouse *

Initials
I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of FLORIDA at the time of this service. Sign Your Initials with finger or mouse*

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I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage. Sign Your Initials with finger or mouse*

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I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to: • It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures. • Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network. • Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures. Sign Your Initials with finger or mouse*

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I agree that information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care. Sign Your Initials with finger or mouse *

Initials
I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records). Sign Your Initials with finger or mouse *

Initials
I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed. Sign Your Initials with finger or mouse*

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I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others. Sign Your Initials with finger or mouse*

initials
The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me. Sign Your Initials with finger or mouse*

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I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit. Sign Your Initials with finger or mouse*

Initials
I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider. Sign Your Initials with finger or mouse*

Initials
I understand that electronic communication cannot be used for emergencies or time- sensitive matters. Sign Your Initials with finger or mouse *

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I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit. Sign Your Initials with finger or mouse*

Initials
I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.). Sign Your Initials with finger or mouse *

Initials
I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications. Sign Your Initials with finger or mouse*

Initials
By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit. Sign Your Initials with finger or mouse*

Initials
I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided. Sign Your Initials with finger or mouse *

Initials
To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit. Sign Your Initials with finger or mouse*

Initials
I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community. Sign Your Initials with finger or mouse*

Initials
I understand that due to the state of the current national emergency crisis, telehealth is offered by DR. AUDREY FARAHMAND to appropriate patients in an effort to comply with federal and state mandates of isolation and social distancing as an effort to provide protection to everyone. The purpose of this form is to obtain your consent for a telehealth visit with one of our healthcare providers at the office of FARAHMAND PLASTIC SURGERY. COSMETIC PROCEDURE/SURGERY The purpose of this visit is for the care of during the national emergency. Sign Your Initials with finger or mouse*

Signature
I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature with the opportunity to have questions answered to my satisfaction. For electronic communication between DR. AUDREY FARAHMAND and staff and (TYPE YOUR FIRST AND LAST NAME)*
Patient's Name
Patient or Legal Representative Signature. SIGN YOUR FULL SIGNATURE WITH YOUR FINGER OR MOUSE*

Patient's Signature
Relationship to Patient*
Print Patient or Legal Representative's Name*
Print Name
Date*

MonthDayYear
Date
Should be Empty:

Surgical Consents

Smokers' Acknowledgement

Illicit/Illegal Drugs and Surgery Warning

Surgical Cost Information

Hospital Privileges

Post-Operative Care Appointments

Pump Consignment Form

Narcotic Alternatives

Pregnancy Waiver for Surgical Procedure

Breast Augmentation Warranty

Mentor Silicone Implant Acknowledgement Informed Decision

Name: Farahmand Plastic Surgery

To

Name: KPOW Anesthesia

Name: Farahmand Plastic Surgery

To

Name: Patient (Self)

FARAHMAND PLASTIC SURGERY COVID-19 RISK INFORMED CONSENT

Farahmand Plastic Surgery

Authorization for Disclosure of Protected Health Information Medical Records Release * Optional

Patient Name:

TELEHEALTH INFORMED CONSENT