All fields marked with an asterisk (*) are requiredPatient Name*PATIENT INFORMATIONREASON FOR TODAY'S VISIT*Date of Birth* MM DD YYYY GenderMaleFemaleMarital StatusMarriedSingleWidowedDivorcedPhone (Home)*Phone (Work)Ext.Phone (Cellular)Email*May we send you updates and information regarding our practice?YesNoMay we leave a telephone message?YesNoNotes on preferred method of contactMay we email you product/service special offers, seminar information, or newsletters at this address?YesNo REFERRED BY: (please specify in the space provided)SelfBulletinMagazineYellow PagesFriendSeminarWebsiteRelativeAnother patientSpa/SalonEmployeeOtherPhysicianInternetAUTHORIZATION FOR DISCLOSURE/RELEASE OF INFORMATIONI authorize Villano|MD to disclose complete information concerning medical finding and treatment of the undersigned, from the initial office visit until date of the conclusion of such treatment, to those individuals who, in Villano|MD's determination, are required to receive such information for the purpose of medical treatment, medical quality assurance, peer review, and if applicable to process the insurance claim for services rendered at Villano|MD.Date MM DD YYYY Signature* PREVIOUS SURGERIES OR SERIOUS ILLNESSESTYPEYEARCOMPLICATIONS?TYPEYEARCOMPLICATIONS?CURRENT MEDICATIONSDRUG/DOSEPRESCRIBED BYDRUG/DOSEPRESCRIBED BYALLERGIESDo you have any drug allergies?YesNoList any medications that you have had a bad reaction toDo you have any skin product or food allergies?YesNoList any products/foods that you have had a bad reaction toPERSONAL INFORMATIONHeightCurrent WeightRecent Weight Loss/Gain?If yes, how much?Do you smoke?YesNoHow many packs?How many years?Do you drink Alcohol?YesNoHow much?How often?HISTORYHave you had (Injected filler, Collagen, etc.) injections?Last injection?Have you had Botox Cosmetic injections?Last injection?Have you had facial surgery?Type and dateHave you ever had laser resurfacing?Type and dateHave you ever had a chemical peel or dermabrasion?Type and dateHave you had a bad reaction to local or general anesthesia?YesNoIf yes, explainHave you had significant emotional problems?YesNoIf yes, explainHave you had psychiatric care?YesNoIf yes, explain Have you seen other plastic surgeons about this same concern?YesNoIf yes, explainDo you have high blood pressure?YesNoIf yes, explainDo you bleed easily from cuts or surgery?YesNoIf yes, explainDo you form large scars or keloids?YesNoIf yes, explainDo you have frequent infections, boils or canker sores?YesNoIf yes, explainDo you have Glaucoma?YesNoIf yes, explainFemales:Have you ever been pregnant?YesNoHow many times?Live births?Are you currently pregnant?YesNoAre you planning more children?YesNoAre you currently breast feeding?YesNoHAVE YOU HAD ANY SERIOUS ILLNESSES OF THE FOLLOWING?Please check. Brain Nose Heart Blood Extremities Eyes Cancer Ears Lungs Abdomen Urinary Nervous Diabetes Reproduction OtherPlease explain, if you checked any of the aboveWould you like to be contacted by our Medical Aesthetician about non-surgical procedures and treatments?YesNoI hereby consent to be examined and treated by Michael E. Villano, MD, and I certify that the above information is correct.Date MM DD YYYY SIGNATURE OF PATIENT OR SPOUSE OR RESPONSIBLE PARTY* Patient namePatient account numberFinancial Policy Thank you for choosing Villano|MD for your cosmetic needs. Our goal is to make your surgical experience a pleasant one. For your convenience, and to avoid any future confusion, we would like to outline our policies and procedures for you. CONSULTATION A complimentary cosmetic consultation is scheduled from your initial telephone call. This consultation is designed for you and Dr. Villano to meet and discuss your surgical needs, outline the procedure, and inform you of the fees. If insurance is involved, there will be an office visit charge. Please note, if you do not show up for your scheduled appointment or do not cancel within 24 hours, we reserve the right to charge a $35 cancellation fee. SCHEDULING After your consultation, if you decide to go ahead with surgery you will work with our patient care coordinator to select a date for your surgery. PRE-PAYMENT There is a $500 or 10%, whichever is greater, scheduling fee deposit required before the date selected can be reserved exclusively for you. This is a non-refundable deposit. This fee is used to cover the booking and scheduling expenses involved with your surgery. This amount will be deducted from your total cost. PRE-OP VISIT Prior to surgery, preferably two (2) weeks, you will meet with the medical assistant and Dr. Villano. Our medical assistant will explain all pre-operative instructions, order lab tests required, review your surgical procedure and post-operative limitations with you, and give you your post-operative prescriptions with instructions for their use. Post-operative appointments are scheduled at this time. Any questions you may have will be answered at this consult. FINAL PAYMENT Two (2) weeks prior to surgery, the remaining balance on your account is due. We accept: Visa, Mastercard, Money Orders, Cashiers Checks. We are sorry but we are unable to accept personal checks for surgery payment. CANCELLATION POLICY If, for any reason, medical or personal, you cancel two weeks or less prior to your scheduled surgery date, fees will be charged as follows: Two (2) weeks prior to surgery — 10% or $500, whichever is greater, of your surgery fee for expenses incurred. One (1) week prior to surgery — 25% of surgical fee One (1) day (24 hours) prior to surgery — full surgical fee If you have any questions about our Financial Policy, please contact us. Our staff will be happy to assist you. Please sign and date.Date MM DD YYYY Financial Guarantor Signature* CONSENT TO TAKING AND PUBLICATION OF PHOTOGRAPHS By my signature below, I hereby consent to before and after surgery photography for the purpose of documenting my plastic surgery in my medical records maintained in the ordinary course of business by Michael E. Villano, MD, LLC. In addition, by checking the appropriate box below, I grant or deny additional limited use(s) of my photographs. For the additional uses, I understand that my name will not be revealed and my photographs may be appropriately edited to maintain anonymity. Photographs used may be cropped as needed to focus on the area of surgery.Show my photographs to other patients in Dr. Villano's office.YesNoPost my photographs on Dr. Villano's website, or web pages in plastic surgery sites displaying Dr. Villano's photos.YesNoUse my photographs to illustrate lectures and presentations to an audience of medical professionals, and to illustrate scientific journal articles or books for medical professionals.YesNoUse my photographs to illustrate newspaper and magazine articles featuring Dr. Villano, or to illustrate presentations or lectures by Dr. Villano to the general public.YesNoAll photographs will be taken only with the approval of Dr. Villano, and under such conditions and at such times as may be approved by Dr. Villano. Photographs may be taken by Dr. Villano, or by an employee or photographer selected by him who has signed a confidentiality agreement concerning patient medical records.NAME OF PATIENTSIGNATURE OF PATIENT OR GUARDIAN (IF PATIENT IS UNDER 18)* ACKNOWLEDGMENT AND CONSENT I understand that Michael E Villano, MD (referred to below as "This Practice") will use and disclose health information about me. I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that This Practice may use and disclose my health information in order to: make decisions about and plan for my care and treatment; refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and perform various office, administrative and business functions that support my physician's efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care. I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in waiting/reception area. I acknowledge that I have been informed that at times, new information about the practice may be promulgated via e-mail. I have the right to refuse receiving this information at any time by notifying the practice in writing. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.Date MM DD YYYY PatientDate MM DD YYYY Patient representativeDescription of Representative's Authority PATIENT REFERRALS RIGHTS Every patient has a choice when referred to a facility for a diagnostic test or health care treatment or service. As a patient you may receive the diagnostic test or health care treatment or service at a facility other than the one recommended by Dr. Villano. If you would like to be seen at a facility other than the facility recommended by Dr. Villano, you may request information regarding alternative facilities at the front desk. You may also speak to Dr. Villano. If you choose to have the diagnostic test, health care treatment or service at a facility different from the one recommended by Dr. Villano, you are responsible for determining the extent of coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the chosen facility.