Dr. J Salomon

    PATIENT INFORMATION / INFORMACION DE PACIENTE


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    (Teléfono del Trabajo)


    (Celular)


    (Correo Electronico)


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    (Sexo)


    (Seguro Social)


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    (Nombre de Esposo/a, Padre o Guardián)


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    (Por Quien Fue Referido)


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    (Su Medico De Cabecera)


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    (Nombre De Contacto de Emergencia)


    (Teléfono De Contacto de Emergencia)

    FOR OFFICE USE ONLY:
    Checked forms:

    Entered in I&E

    DL

    “PHYSICIAN’S RELEASE AND ASSIGNMENTS”

    I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED BY ME, AND I AGREE THAT IN THE EVENT THAT THIS ACCOUNT IS REFERRED TO COLLECTIONS, I WILL PAY ALL THE COLLECTION EXPENSES, ATTORNEY FEES AND COURT COSTS.

    I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION REQUIRED BY MY INSURANCE CARRIER (S). A COPY OF THIS AUTHORIZATION MAY BE USED IN LIEU OF THE ORIGINALS. I FURTHER AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION AND HEALTH CARE FINANCING ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM.

    I REQUEST PAYMENT OF MEDICAL INSURANCE BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR CHARGES NOT COVERED BY THIS AUTHORIZATION, AND I AGREE THAT IN THE EVENT THAT THIS ACCOUNT IS REFERRED TO COLLECTIONS, TO PAY ALL COLLECTION EXPENSES, ATTORNEY FEES, AND COUR COSTS.

    “LA LIBERACION DE MEDICO Y TAREAS”

    YO COMPRENDO QUE SOY FINANCIERAMENTERESPONSABLE POR TODOS LOS CARGOS CONTRAIDOS POR MI, Y YO CONCUERDO QUE EN EL CASO DE QUE ESTA CUENTA SEAREFERIDA A COLECCIONES, YO PAGARE TODOS LOS GASTOS DE COLECCIÓN, TODOS LOS GASTOS DE ABOGADO Y LOS COSTOS DE LA CORTE.

    POR MEDIO DE LA PRESENTE Y COMO FUERASOLICITADO POR MI COMPANIA DE SEGURO, CONCEDO ACCESO A CUALQUIER INFORMACION EN REFERENCIA A MI HISTORIAL CLINICO. UNA COPIA DE ESTA AUTORIZACION PUEDE SER USADA EN LUGAR DE LA ORIGINAL. PARA FINES DE SERVICIOS DE MEDICARE AUTORIZO A CUALQUIERA EN POSESION DE DICHA INFORMACION EL PODER DE COMPARTIRLA CON LA ADMINISTRACION DEL SEGURO SOCIAL Y LA ASOCIACCION FINANCIERA DE ADMINISTRACION DE SALUD Y SUS INTERMEDIARIOS O DISTRIBUIDORES.

    A SU VEZ SOLICITO EL PAGO DE BENEFICIOS DE SEGURO MEDICO A MI MISMO O A UN TERCERO. COMPRENDO QUE SOY RESPONSABLE FINANCIERAMENTE DE LOS CARGOS NO CUBIERTOS POR ESTA AUTORIZACION Y POR CARGOS DE ABOGADOS Y CORTES, EN CASO DE QUE ESTA CUENTA SEA REFERIDA A RECAUDADORES.


    (Firma De Paciente)


    (Fecha)

    “IF YOU DO NOT KNOW THE INFORMATION PLEASE WRITE “DO NOT KNOW” ON THE LINE PROVIDED”(SI USTED DESCONOCEESTAINFORMACIONPOR FAVOR ESCRIBA “NO LO SE” EN LA LINEA)


    (Nombre de Medico de Cabecerao)


    (Dirección)


    (Teléfono)


    (EstaUsted Bajo Cuidado Medico Actualmente?)

    YES / SINO


    (Desde Cuando?)


    (Porque?)


    (Cuando Fue Su Ultimo Examen Físico?)


    (Esta Usted Tomando Medicamentos? (Si Su Respuesta es Si, Por Favor Menciónelas.)

    YES / SINO


    (Toma Usted Rutinariamente Alguna Sustancia Relacionada Con Su Salud (Vitaminas, Medicinas Naturales? (Si Su Respuesta es Si, Por Favor Menciónelas.)

    YES / SINO


    (Es Usted Alérgico/a a Alguna Medicina o Sustancia? (Si Su Respuesta es Si, Por Favor Menciónelas.)

    YES / SINO


    (Usted tiene la enfermedad G6PD o Hemochromatosis?)

    YES / SINO


    (Tiene Usted Algunas Otras Alergias? (Si Su Respuesta es Si, Por Favor Menciónelas.)

    YES / SINO


    (Tiene Usted Algún Problema Con Penicilina, Antibióticos, Anestésicos, o Con Otras Medicinas? (Si Su Respuesta es Si, Por Favor Menciónelas.)

    YES / SINO


    (Tiene usted en su historial médico familiar un evento de muerte súbita o inesperada luego de recibir anestesia general o después de hacer ejercicios?)

    YES / SINO


    (Tiene usted en su historial médico personal o familiar, el padecimiento de hipotermia maligna?)

    YES / SINO


    (Tiene usted en su historial médico personal o familiar, el padecimiento de alguna patología muscular o neuromuscular?)

    YES / SINO


    (Tieneusted en su historial médico personal o familiar, eventos de altas temperaturas después de hacer ejercicios?)

    YES / SINO


    (Tiene usted en su historial médico el padecimiento de espasmos musculares? )

    YES / SINO


    (Tiene usted en su historial médico personal o familiar, eventos en los que ha expelido orina de color oscuro o ha experimentado fiebres inmediatamente después de recibir anestesia o de realizar ejercicios fuertes?)

    YES / SINO


    (Es Usted Sensible aAlgúnMetal o al Látex?)

    YES / SINO


    (Ha SidoTratado o Alguna Vez Le Han Dicho Que Pudiera Tener Alguna Enfermedad Cardiaca?)

    YES / SINO


    (Alguna Vez Ha Tomado Usted La Píldora De Dieta, PHEN-FEN?)

    YES / SINO


    (Tiene Usted La Presión Baja o Alta?)

    YES / SINO


    (Tiene Usted Un Marcapaso, Injerto Artificial De Corazón o Implante De Válvula?)

    YES / SINO


    (Ha Padecido Alguna Vez de Fiebre Reumática?)

    YES / SINO


    (Sabe Usted Si Tiene Algún Soplo En El Corazón?)

    YES / SINO


    (Ha ExperimentadoUsted Alguna Enfermedad Grave o Cirugía Mayor? (Si Su Respuesta Es Si, Por Favor Liste Las.)

    YES / SINO


    (Ha RecibidoAlguna Vez,Tratamiento De RadiaciónoQuimioterapia, seapor un Tumor o Alguna Otra Condición?)

    YES / SINO


    (PadeceUsted de Alguna Enfermedad Inflamatoria como Artritis o Reumatismo?)

    YES / SINO


    (Tiene Usted Alguna Coyuntura Artificial o Prótesis?)

    YES / SINO


    (PadeceUsted de Alguna Enfermedad De Sangre Tales Como Anemia o Leucemia Etc.?)

    YES / SINO


    (Ha UstedAlguna VezSangrado Excesivamente Después DeHaberseCortado o Herido?)

    YES / SINO


    (Tiene Usted Algún Problema DeEstomago, Riñones, Tiroides o Hígado?)

    YES / SINO


    (Es Usted Diabético/a?)

    YES / SINO


    (SufreUsted De Asma?)

    YES / SINO


    (PadeceUsted De Epilepsia o Ataques Epilépticos?)

    YES / SINO


    (Tiene Usted o Ha Tenido Alguna Vez Alguna Enfermedad Venérea?)

    YES / SINO


    (Se Ha Hecho Usted Alguna Vez La Prueba Para El Sida?)

    YES / SINO


    (Tiene Usted Sida?)

    YES / SINO


    (Ha Padecido Alguna Vez o Padece Usted De Hepatitis?)

    YES / SINO


    (Ha Sido Alguna Vez Diagnosticado Con AlgunaEnfermedad Pulmonaria o Tuberculosis?)

    YES / SINO


    (Fuma o MasticaUstedAlgún TipoDe Tabaco?)

    YES / SINO


    (Si Su Respuesta Es Si, Cuanto Fuma?)


    (Consume Usted Bebidas Alcohólicas? (Si Su Respuesta Es Si, Que Tanto?)

    YES / SINO


    (Tiene UstedPor Habito El Uso DeSustancias Controladas?)

    YES / SINO


    (Ha Sido Usted Alguna Vez Tratado Por Enfermedad Mental o RecibidoTratamiento Psiquiátrico?)

    YES / SINO


    (Padece Usted DeAlguna Enfermedad, Condición o Problema Que No HayaSido Mencionado? (Si Su Respuesta es Si, Por Favor Menciónelas.)

    YES / SINO


    (Esta Usted Embarazada o Sospecha Que Pueda Estarlo?)

    YES / SINON/A


    (Utiliza Usted Algún Medicamento De Anticonceptivo?)

    YES / SINON/A


    (Tiene Usted El Periodo Regularmente?)

    YES / SINON/A


    (Tiene Usted o Tuvo Ya La Menopausia?)

    YES / SINON/A

    “I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE” (Yo Certifico Que La Información De Encima Esta Completa y Correcta.)


    (FirmaDelPaciente)


    (Fecha)

    YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE”

    UNDER FLORIDA LAW, PHYSICIANS ARE GENERALLY REQUIREDTO CARRY MEDICAL MALPRACTICE INSURANCE OR OTHERWISE DEMONSTRATE FINANCIAL RESPONSIBILITY TO COVER POTENTIAL CLAIMS FOR MEDICAL MALPRACTICE. THIS IS PERMITTED UNDER FLORIDA LAW SUBJECT TO CERTAIN CONDITIONS. FLORIDA LAW IMPOSES PENALTIES AGAINST NON-INSURED PHYSICIANS WHO FAIL TO SATIFY ADVERSE JUDGEMENTS ARISING FROM CLAIMS OF MEDICAL MALPRACTICE. THIS IS PROVIDED UNDER PURSUANT TO FLORIDA LAW.

    “SU DOCTOR HA DECIDIDO NO TENER SEGURO DE MALAPRACTICA”

    BAJO LA LEY DEL ESTADO DE LA FLORIDA, SE REQUIRE QUE LOS DOCTORES EN MEDICINA TENGAN SEGUROS DE MALA PRACTICA O DE LO CONTRARIO DEBENDEMOSTRAR QUE SON FINANCIERAMENTE REPONSABLES PARA PODER CUBRIR RECLAMOS DE MALA PRACTICA MEDICA. ESTO ES PERMITIDO BAJO LA LEY DE LA FLORIDA BAJO CIERTAS CONDICIONES. LA LEY DELA FLORIDA IMPONE PENALIDADES A LOS DOCTORES QUE NO ESTEN ASEGURADOS Y QUE NO SATISFAZGAN JURISDICCIONES ADVERSAS POR DEMANDAS EN SU CONTRA COMO RESULTADO DE UNA MALA PRACTICA MEDICA. ESTA NOTA ESTA BASADA BAJO LA LEY DE LA FLORIDA.


    (Firma DelPaciente)


    (Fecha)


    (EscribaSu Nombre)

    “CONSENT FOR THE USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION”

    I HEREBY GIVE CONSENT TO JHONNY SALOMON, M.D., P.A. AND ALL HEALTH CARE PROVIDERS FURNISHING CARE WITHIN THE PRACTICE TO USE AND DISCLOSE MY PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

    MY “PROTECTED HEALTH INFORMATION” MEANS THAT HEALTH INFORMATION, INCLUDING MY DEMOGRAPHIC INFORMATION, COLLECTED FROM MEAND CREATED OR RECEIVED BY MY PHYSICIAN, ANOTHER HEALTH CARE PROVIDER, A HEALTH PLAN, MY EMPLOYER, OR A HEALTH CARE CLEARINGHOUSE. THIS PROTECTED HEALTH INFORMATION RELATES TO MY PAST, PRESENT, AND FUTURE PHYSICAL AND MENTAL HEALTH CONDITION. IT IDENTIFIES ME OR THERE IS A REASONABLE BASIS TO BELIEVE THE INFORMATION MAY IDENTIFY ME.

    PLEASE BE ADVISED THAT OUR NOTICE OF PRIVACY PRACTICES PROVIDES MORE DETAILED INFORMATION ABOUT HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION. YOU HAVE THE RIGHT TO REVIEW OUR NOTICE OF PRIVACY PRACTICES BEFORE YOU SIGN THIS CONSENT.WE RESERVE THE RIGHT TO REQUEST AND RESTRICT HOW WE USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS. WE ARE NOT REQUIRED TO GRANT YOUR REQUEST, BUT IF WE DO, THE RESTRICTION WILL BE BINDING ON US.

    YOU MAY REVOKE THIS CONSENT AT ANY TIME. YOUR REVOCATION MUST BE IN WRITING, SIGNED BY YOU OR ON YOUR BEHALF, AND DELIVERED TO OUR PRESENTADDRESS. YOU MAY DELIVER YOUR REVOCATION BY ANY MEANS YOU CHOOSE BUT IT WILL BE EFFECTIVE ONLY WHEN WE ACTUALLY RECEIVE THE REVOCATION. YOUR REVOCATION WILL NOT BE EFFECTIVE TO THE EXTENT THAT OTHERS ARE OR WE HAVE ACTED IN RELIANCE UPON THIS CONSENT.

    “CONSENTIMIENTOPARA EL USO Y/O REVELACION DE LA INFORMACION DE SALUD PROTEGIDA”

    YODOY MI CONSENTIMIENTO AL DOCTOR JHONNY SALOMON, M.D., P.A. Y A TODOSSUSPROVEEDORES DE ASISTENCIAMEDICA QUIENESPROPORCIONAN EL CUIDADO MEDICODENTRO DE LA PRACTICA A UTILIZAR Y REVELAR MI INFORMACION DE SALUD PROTEGIDA SI FUESE NECESARIOPARATRATAMIENTOS, PAGOS Y OPERACIONES DE ASISTENCIA MEDICA.

    MI “INFORMACION DE SALUD PROTEGIDA”SIGNIFICA EINCLUYE MI INFORMACION DEMOGRAFICA QUE FUE ENTREGADA Y CREADA POR MI Y RECIBIDA POR MI MEDICO, POR OTRO PROVEEDOR DE ASISTENCIA MEDICA, POR UN PLAN DE SALUD, POR MI EMPLEADOR, O POR UN BANCO DE LIQUIDACION DE ASISTENCIA MEDICA. ESTA INFORMACION PROTEGIDA DE SALUD ES RELACIONADA A MI PASADO, PRESENTE, Y EL FUTURO DE MI SALUD FISICA O MENTAL. ME IDENTIFICA, O HAY UNA BASE RAZONABLE DE CREER QUE LA INFORMACION ME IDENTIFICA.

    ESTOY EN PLENO CONOCIMIENTO DE QUE LANOTA DE PRACTICAS DE INTIMIDAD PROPORCIONA INFORMACION MAS DETALLADA SOBRE COMO ESTA PRACTICA UTILIZA Y PUDIERA REVELARMIINFORMACION DE SALUD PROTEGIDA. TENGOLA OPCION Y ELDERECHO DE REVISAR LANOTA DE PRACTICAS DE INTIMIDAD ANTES DE FIRMARESTE CONSENTIMIENTO. DR. JHONNY SALOMON, M.D. P.A. Y TODOS SUS PROVEEDORES SE RESERVANEL DERECHO DE SOLICITAR Y RESTRINGIR EL USO QUE PUDIERAN DAR AMIINFORMACION DE SALUD PROTEGIDA CON EL PROPOSITO DE TRATAMIENTO, PAGO, O DE LAS OPERACIONES DE ASISTENCIA MEDICA.

    USTED PUEDE REVOCAR ESTE CONSENTIMIENTO A CUALQUIER HORA. SU REVOCACION DEBE ESTAR EN ESCRITO, FIRMADA POR USTED O EN SU BENEFICIO, Y ENTREGADA A NUESTRO DOMICILIOACTUAL. USTED PUEDE ENVIARSU REVOCACION POR EL MEDIO QUE PREFIERA, SIEMPRE Y CUANDO SEA EFECTIVO YNOSOTROS RECIBAMOS REALMENTE LA REVOCACION. SU REVOCACION NO SERA EFECTIVA HASTA QUE OTROS HAYAN ACTUADO O EN LA DEPENDENCIA DEESTE CONSENTIMIENTO.


    (Firma DelPaciente)


    (Fecha)


    (EscribaSu Nombre)

    IF YOU ARE SIGNING AS THE PATIENT’S REPRESENTATIVE PRINT YOUR NAME AND DESCRIBE YOUR AUTHORITY: (Si Usted Firma Como El Representante Del Paciente EscribaSu Nombre y ExpliqueSu Autoridad)


    (Firma)


    (Fecha)

    I authorized the following individual(s) to receive information regarding my protected heath information.


    (Nombre)

    PLEASE DO NOT WRITE BELOW. FOR OFFICE USE ONLY. THANK YOU. ( POR FAVOR NO ESCRIBA DEBAJO. PARA EL USO DE LA OFICINASOLAMENTE. GRACIAS. )



    M.D.
    (Revisado Por)


    (Fecha)

    Physician – Patient Arbitration Agreement

    Preface:

    I, Dr. Jhonny Salomon, have decided under Florida Law to practice without Malpractice insurance. Under this practice, this Arbitration Agreement (“Agreement”) should be read carefully and fully understood. If you have any questions before or after reading and signing this statement please ask the staff or my office manager. Please read this document clearly. Thank you for your consideration.


    Article 1:
    Agreement to Arbitrate: It is understood that my dispute as to medical malpractice that is, as to whetherany medical services rendered under this contract were unnecessary, authorized or were improperly, negligently, or incompletely rendered, will be determined by submission to arbitration as provided by the Florida Arbitration Code, Chapter 682, and not by a lawsuit except as Florida law provides for judicial review or arbitration proceeding. Both Parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use ofarbitration.


    Article 2:
    All Claims Must Be Arbitrated: It is the intention of the parties that this Agreement bind all parties whose claims may arise out if related treatment or services provided by the physician including any spouse or heir of the patient or any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of a pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associate, association, corporation or partnership, and the employees, agents and estates of any of them must be arbitrated including,without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filling of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.


    Article 3:
    Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties and must be within the time frame set forth in F.S.95.11 dealing with medical malpractice. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of demand for neutral arbitrator by either party. Each party to the arbitration shall pay such party’s prorated share of the expenses and fees to the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a partyfor such party’s own benefit. Arbitration shall take place within 30 days after the completion of discovery as provided in the Florida Rules of Civil Procedures (Rules 1.0280-1.0390) and the decision of the arbitration panel shall be binding upon the parties for all purposes. The time to responding to discovery requests shall be 10 days. All discoveries shall be completed within 2 months after the appointment of the panel of arbitrators, unless the time for the discovery is extended for good cause by the panel. The arbitration panel shall decide any disputes regarding discovery. The arbitration panel is expressly authorized to award all reasonable fees and costs, including attorney’s fees, to the prevailing party against any part who has violated this Agreement. The parties agree that the arbitrators have the immunity of a judicial officer for civil liability when acting in the capacity of arbitrator under this contract. The immunity shall supplement, not supplant, any other applicable statutory or common law provisions.

    Either party shall have the absolute right to arbitrate separately the issues of liability and damages, upon written request to arbitrate separately the issues of liability and damages, upon written request to the neutral arbitrator. Theparties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be proper additional party in court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

    Article 4:
    General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in on proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in civil action, would be barred by the applicable Florida statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for the arbitrator shall be governed by the Florida Rules of Civil Procedure provisions relation to arbitration.

    I have read and understood all information presented to me before signing. I understand that I have the right to receive a copy of this Arbitration Agreement.

    (Patient’s or Patient’s Representative’s Signature*)

    Date*

    If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect and shall not be affected by the invalidity of any other provisions.

    *** Cancellation Policy for Spa ***

    As a courtesy to all, we ask that a 24 hour notice be given if you need to cancel or change your appointment with us.For a cancellation with less than 24 hour notification, guests will be charged 50% of the treatment fee. For no-show appointments, the full treatment fee will be charged.For spa procedures that are pre-paid, if the patient does not complete the treatments a credit will be available for use on future spa treatments.

    Como cortesia para todos, solicitamos que se le de un aviso de 24 horas si necesita cancelar o cambiar su cita con nosotros. Para una cancelacion con menos de 24 horas de notificacion, los huespedes deberan pagar el 50% de la tarifa de tratamiento en su tarjeta de credito. Para citas fuera de show, se cobrara la tarifa de tratamiento completo. Esta politica incluye, pero no se limita a, depilacion laser, masajes y citas con esteticistas.

    *** Cancellation Policy for Non-Surgical Procedures ***

    A 50% deposit is required to schedule your non-surgical procedure - this deposit is non-refundable, non-reusable, non-transferable. Final payment is due the day of your procedure. This policy includes but is not limited to Cavitaiton, Cooslculpting, Cosmetic laser treatments, CO2, HCG, Fat Grafting, Fraxel, IPL, Microblading, Microneedling, Myers Cocktail, PRP, Thermage, Thermiva, Sclerotherapy, Tattoo removal, Velashape and procedures performed under local anesthesia.

    Se require un deposito del 50% para programar su procedimiento no quirurgico; este deposito no es reembolsable, no reutilizable, no transferible. El pago final se vence el dia de su procedimiento. Esta politica incluye, pero no se limita a Cavitacio, Coosculpting, tratamientos con laser cosmetico, CO2, HCG, Injerto de Grasa, Fraxel, IPL, Microblading, Microneedling, Myers cocktail PRP, Thermage, Thermiva, Sclerotheraphy, eliminacion de tatuajes, Velashape y procedimientos realizados en locales.

    *** Cancellation Policy for Surgery ***

    A 15% deposit is required to schedule surgery - minimum being $1,000. This deposit secures your surgery date and required resources and is non-refundable, non-transferable and non-reusable. Full payment is required 14 calendar days before your procedure - if payment is not received your surgery may be canceled. When procedure is paid in full, monies are not refundable unless there is a medical emergency validated in writing by a physician.

    This policy includes but is not limited to Abdominoplasty, Blepharoplasty, Brachioplasty, Breast Augmentation/ Lift/ Reduction, Brow Lift, Buccal Fat REmoval, Chin/Cheek Augmentation, Facelift, Gynocomastia, Labiaplasty, Liposuction, Neck Lift, Otoplasty and Rhinoplasty.

    If there is a need for surgical revision this will be assesed with the surgeon. If an operating room is needed for the revision, the payment will be the responsibility of the patient. However, the surgeon's fee in most instances will be waived for the revision.

    We are commited to making your surgical experience a postive one. We need your assistance in completing all the required medical clearance testing 10 days prior to your surgery date. If these requirements are not completed within the required time, your surgery may be canceled.

    Se require un deposito del 15% para programar la cirugia, siendo el minimo de $1,000. Este deposito asegura al fecha de su cirugia y los recursos requiridos, y no es reembolsable, no transferible y no reutilizable. Se requiere el pago completo 14 dias calendario antes de su procedimiento; si no se recibe el pago, su cirugia puede ser cancelada. Cuando el procedimiento se paga en su totalidad, el dinero no es reembolsable a menos que haya una emergencia medica validada en escrito por un medico.

    Esta politica incluye, pero no se limita a Abdominoplastia, Bleforoplastia, Braquioplastia, Aumento / Levantamiento / Reduccion de senos, Levantamiento de Cejas, Remocion de Grasa Bucal, Aumento de Mention / Barbilla, Lifting Facial, Gynocomastia, Labioplastia, Liposuccion, Lifitng de Cuello, Otoplastia y Rinoplastia.

    Si hay una necesidad de revision quirurgica, esto se eveluara con el cirujano. Si se necisita un quirofano para la revision, el pago sera responsibilidad del paciente. Sin embargo, la tarifa del cirujano en la mayoria de los casos no se aplicara para la revision.

    Estamos comprometidos a hacer que su experiencia quirirgica sea positiva. Necesitamos su ayuda para completar todas las pruebas de aprobacion medica requeridas 10 dias antes de la fecha de su cirugia. Si estos requisitos no se completan dentro del tiempo requirido, su cirugia puede ser cancelada.


    (Firma Del Paciente o De Su Representante*)

    2019 Novel Coronavirus Screening Questionnaire



    Please Circle YES or NO to the following questions:


    YESNO


    YESNO


    YESNO


    YESNO


    This document is for reference purpose only. It is intended to provide general guidance, is not legal advice and is not a statement regarding any standard of care.
    This document does not take into account every law or requirement of federal, state or local authorities which may be applicable to you or your practice site(s).

    Informed Consent

    COVID-19 RISK

    2020 American Society of Plastic Surgeons. Purchases of the Informed Consent Resource are given a limited 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.

    Informed Consent - COVID-19 RISK

    COVID-19 RISK INFORMED CONSENT

    I (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 coronovirus, 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 recomended social
    distancing. I recognize that Dr. Jhonny Salomon is closely monitoring the situation and has put in place
    reasonable preventative measures aimed to reduce the spread with 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. Jhonny Salomon 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/suregery may
    result in the following: a posituve COVID-19 diagnosis, extended quaratine/self-isolation, additional tests,
    hospitalization that may require medical therapy, Intesive Care treatment, 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 THE EXPLANATION AND HAVE NO MORE QUESTIONS AND CONSENT TO THE PROCEDURE.





    Page 1 of 2Patient Initials2020 American Society of Plastic Surgeons
    This form is for reference only. It is a general guideline and not a statement of standard of care. Rather, this form should be edited and amended to reflect policy requirements of your practice sites(s),
    CMS and Joint Commission requirements, if applicable, and legal requirements of your individual states. The American Society of Plastic Surgeons does not authorize the use of these documents for purposes
    of any research or study. The ASPS does not certify that this form, or any modified version of this form, meets the requirements to obtain informed consent for this procedure in the jurisdiction of your pratice.