Cosmetic Intake Form-Dr.Dev Vibhakar
  • Cosmetic Intake Form-Dr.Dev Vibhakar

  • ABOUT DR. DEV VIBHAKAR-

    Cosmetic and reconstructive surgery is where “art” and “science” blend to combine intuition, creativity and artistic sense with extensive surgical training, discipline and medical knowledge.

    Dr. Dev Vibhakar performs cosmetic surgery, body contouring and is fellowship trained at Harvard Medical School-Massachusetts General Hospital in adult facial aesthetics and reconstructive surgery. He also has specialized training in reconstructive surgery for birth defects, traumatic injuries and deformities from cancer including microsurgery and breast reconstruction.

    Dr. Dev Vibhakar is committed to fully educating his patients about their individual procedures and will spend the time necessary to discuss all possible techniques and alternatives. His goal is to provide exceptional and natural appearing results on a consistent basis. He is privileged to have trained in programs that treat patients from all parts of the United States and from numerous countries around the world.

    In his quest to ensure that his patients receive the benefits of the latest technologies and advances in cosmetic and reconstructive surgery, Dr. Dev Vibhakar routinely attends seminars, training and continuing medical education courses. He has been invited to lecture at national meetings on topics that involve facial skeletal augmentation and reconstruction of skull defects.

  • Social History


  • Review of Systems



  • Notice of Privacy Practices Acknowledgement

    I have reviewed a copy of Dr. Rankin’s Notice of Privacy Practices.
    (If you desire a printed copy of the notice, please notify the receptionist. )

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  • Dr. Dev B. Vibhakar
    Aqua Plastic Surgery
    641 University Blvd, Suite #103

    Jupiter, Florida 33459 Phone: 561-776-2830 Fax: 561-296-4156

    PHOTOGRAPHY CONSENT
    “I hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery, Inc.”

  • Witness Signature

     

     

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  • The Board requires that all identifiable characteristics, with the exception of a full face photograph or photograph of a uniquely identifiable characteristic, be blanked out for submission of materials for the Oral Examination of The American Board of Plastic Surgery to protect patient privacy.

    **PLEASE NOTE: THIS FORM MUST BE SIGNED IN ORDER TO HAVE ANY PROCEDURE
    PERFORMED

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