&date&

Aesthetic Facial Surgery Center of New York Drivers License number (if a minor, please use guarantor) Issuing State: May we email you monthly skin care special offers: Y N Referred by: (please specify in the space provided) Self I authorize medical treatment of the person named above and agree to pay all fees and charges for such treatment. I authorize Aesthetic Facial Surgery Center of New York 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 Aesthetic Facial Surgery Center of New York 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 Aesthetic Facial Surgery Center of New York. I understand that I am responsible for any balance due for professional services in excess of the benefits provided by my policy. I agree to pay for services not covered by my insurance policy. I understand I am responsible for obtaining any prior authorizations required by my insurance policy. I understand that in the event of collection action, I am responsible for any legal fees incurred. Signature: Aesthetic Facial Surgery Center of New York 44 East 65th Street, Suite 1A New York, NY 10021 212-628-6464 Aesthetic Facial Surgery Center of New York Acknowledgment and Consent

I understand that Aesthetic Facial Surgery Center of New York (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 • 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 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.
Aesthetic Facial Surgery Center of New York 44 East 65th Street, Suite 1A New York, New York 10021 212-628-6464 Aesthetic Facial Surgery Center of New York
ALLERGIES
List
CURRENT MEDICATIONS
Drug
PAST MEDICAL HISTORY

Have you ever had any of the following? Please circle all that apply
Anemia
Illnesses Date
Hospitalizations
Injuries
List all surgeries

FAMILY HISTORY
Relative
Known Illnesses


HISTORY OF TOBACCO
Aesthetic Facial Surgery Center of New York 44 East 65th Street, Suite 1A New York, NY 10021 212-628-6464 Aesthetic Facial Surgery Center of New York Have you ever smoked? Yes No If yes, when?
HISTORY OF ALCOHOL
Do you drink alcohol? Yes No Recovery Alcoholic? Yes No Probably an Alcoholic? Yes No

HISTORY OF RECREATIONAL DRUGS
Have you ever used illicit drugs? Yes No
Do you currently use illicit drugs? Yes No Drug(s) of choice COSMETIC HISTORY
Have you had (Restylane, Collagen, etc.) injections? Have you had a bad reaction to local or general anesthesia? Have you had significant emotional problems? Have you seen other plastic surgeons about this same problem? YES NO If yes, explain Do you bleed easily from cuts or surgery? Do you have frequent infections or boils? I hereby consent to be examined and treated by Oleh Slupchynskyj, MD and that the above information is correct. _________________________________________________________________________________________________________________________ Aesthetic Facial Surgery Center of New York 44 East 65th Street, Suite 1A New York, NY 10021 212-628-6464 Aesthetic Facial Surgery Center of New York COSMETIC FINANCIAL POLICY

Consultation:
A $125 consultation fee will be charged. If you should decide to have surgery this fee will be applied to the surgeon fee.
Payment Options:
We accept Visa, MasterCard and cash. Outside financing options are available. We will be able to supply information at your
appointment or you can visit our website to receive more information.

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 deposit required before the date selected can be reserved exclusively for you. The deposit is $500.00 or 10% of surgery
cost whichever is greater. 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-Surgical Visit
Prior to surgery, preferably two (2) weeks, you will meet with the medical assistant. 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.
Surgery Final Payment
Two (2) weeks prior to surgery, you will be expected to pay the remaining balance due on your account. We accept: Visa, Mastercard,
Money Orders, Cashiers Checks. We are sorry but we are unable to accept personal checks for surgery payment.
Cancel Policy: If for any reason, medical or personal, you cancel two weeks or lees 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 – entire surgical fee. If you have any questions, the staff will be happy to assist you. We look forward to caring for you. Please sign and date. Aesthetic Facial Surgery Center of New York 44 East 65th Street, Suite 1A New York, NY 10021 212-628-6464

Source: http://www.facechange.org/pdf/COSMpacket.pdf