PROCEDURES PERFORMED Dr. Rehnke regularly performs each of the surgical procedures listed here. You can be confident that the doctor is experienced and specially trained in each one. Our office staff is also knowledgeable about these procedures and will be able to give you thorough information to help you understand the benefits as well as risks of each one.

▪ BREAST COSMETIC

Breast Augmentation with Autologous Fat Grafting & Internal Mastopexy Breast Enlargement Breast Enlargement without Breast Implants [Autologous Fat Grafting] Breast Enlargement with Implants [Endoscopic Augmentation] Breast Enlargement with Implants [Subglandular Augmentation] Breast Enlargement with Implants [Submuscular Augmentation] Breast Lift [with Internal Mastopexy] Breast Lift [Concentric Mastopexy] Breast Lift [Standard Mastopexy] Removal & Replacement of Breast Implants [Explanation of Breast Prosthesis with Secondary Augmentation Mammoplasty] Removal of Breast Implants with Internal Mastopexy and Fat Grafting Male Breast Reduction [Reduction of Gynecomastia] ▪ BREAST – RECONSTRUCTIVE

Biopsy or Removal of Breast Lump [Breast Biopsy or Lumpectomy] Reconstructive Breast Surgery Without Breast Implants [Autologous Fat Grafting] Breast Reconstruction – Latissimus [Latissimus Dorsi Myocutaneous Flap] Breast Reconstruction with Implant Breast Reduction [Reduction Mammaplasty] Nipple Reconstruction [Nipple-Areolar Complex Reconstruction] Removal of Breast Implants [Capsulectomy with Explanation of Breast Prosthesis] Removal of Breast Tissue [Subcutaneous Mastectomy] Revision of Breast Enlargement [Capsulectomy (Subglandular Reaugmentation)] Revision of Breast Enlargement [Capsulectomy (Subpectoral Reaugmentation)] ▪ BODY CONTOURING

Lifting Thighs and Removal of Abdominal Skin [Lower Body Lift] Liposuction [Suction Assisted Lipectomy] Thigh-Buttock Lift [Thighplasty] Tummy Tuck [Abdominoplasty] Upper Arm Lift [Brachioplasty]

PROCEDURES PERFORMED ▪ FACIAL

Chin Enlargement [with Fat Grafting] Eyelid Lift [Blepharoplasty] Facelift [Rhytidectomy] Forehead Lift [Direct Brow lift] Forehead Lift [Endoscopic Brow lift] Lower Eyelid Lift [Trans-Conjunctival Blepharoplasty] Lower Eyelid Suspension [Canthopexy] Midface Lift Neck Lift [Submental Lipectomy] Fat Grafting Nano Fat Grafting to Deep Dermis ▪ EARS

Ear Pinning [Otoplasty]

▪ SKIN & SCARS Reconstructive Skin Repair [Skin Flaps] Removal of Skin Lesions [Excision of Skin Tumors and Cysts] Scar Repair Using Z-Plasty Technique [Z-Plasty Scar Revision]

PLEASE VISIT DAYGLO MED-SPA § Dr. Robert Rehnke and DayGlo Med-Spa are proud to offer corrective, advanced medical skin care

that utilizes the most progressive treatments and products. SERVICES PROVIDED BY OUR NURSE PRACTITIONERS FILLERS AND INJECTABLES Juvederm Voluma Botox Volbella Kybella Xeomin Belotero Radiesse Restylanne Silk NON-SURGICAL FACIAL REJUVENATION Kybella    PDO  Threads       MICRONEEDLING WITH RF (RADIO FREQUENCY)  Lutronic  -­‐INFINI                

O V E R V I E W *

REGISTRATION We request basic information for our administrative records and provide you with an overview of the consultation process. The fee for consultation is $50.00. We accept cash, check, MasterCard, Visa, American Express and Discover.

SURGEON CONFERENCE

Dr. Rehnke will talk with you about your wishes and desires. He will examine you and give you his opinion about how to achieve your goals. We believe you need to be well-informed about the actual process of preparing for, and recovering from, cosmetic or reconstructive surgery.

Choosing a surgeon is an intensely personal decision. We encourage you to take time to ask the doctor and his staff any questions you may have. We believe the formation of a personal bond is an integral part of the surgery and healing process.

COST/TIMING When you briefly meet with the Patient Coordinator, she will discuss fees and costs. The consultation fee will be collected at this time. If you have a specific date in mind, we will do our best to accommodate your schedule. If you are still in the information gathering phase, she will try to be sure all of your questions are answered.

ANESTHESIA Prior to surgery, you will have an opportunity to discuss your concerns and wishes with your Anesthesiologist.

FOLLOW UP After your procedure, you will be seen for a follow up appointment. At that time, please feel free to ask any further questions you may have for Dr. Rehnke or the members of our staff.

CERTIFICATION Dr. Rehnke is board certified in Plastic Surgery. Our Operating Room is also certified by the American Association for Accredidation of Ambulatory Surgery Facilities (AAAASF). All professional staff are ACLS certified.

Robert D. Rehnke, M.D., F.A.C.S.

. . . . . . . . . . . . . . . . . . . . . . . . . . . (727) 341-0337

Board certified by both the American Board of Plastic Surgery and the American Board of Surgeons

p. 727.341.0337 ! 6606 10th Avenue N., St. Petersburg, FL 33710 ! www.rehnkemd.com

Name:

Address: City: State: Zip:

Social Security No.:

Email: � Home

Name of Family Physician:

Contact in Case of Emergency:

Date:

Date of Birth:

Cell Phone:

Home Phone:

Indicate Best Phone: � Cell

Family Doctor Ph:

Emergency Ph:

Occupation: Employer:

Would you like to receive notifications/reminders of appts via (check all that apply): � Text � Email � Phone

Marita l Status : � Single � Married � Widowed � Divorced � Separated Sex: � Male � Female

Reason for Vis i t : � Breast Augmentation � Breast Reduction Facial Rejuvenation: � Forehead � Face � Eyes

Body Contouring: � Abdomen � Hips/Legs � Arms � Fat Transfer (indicate where):

� Other:

How were you referred to Dr. Rehnke?

� Physician’s Name: � Friend’s Name:

�Website Name: � Other:

Insurance Informat ion: is required and kept on file for emergency purposes, even if your procedure is not covered by insurance. Insurance Carrier:

Address: Telephone Number: Policy Number: Group Number:

Insured Name:

Consent for Treatment : I, undersigned, hereby consent to and authorize all diagnostic and therapeutic considered or advisable in the

judgment of the attending physician.

Author izat ion to Release Informat ion: I authorize the release of any medical information to process my health insurance claim form, if applicable.

Signature: Date:

patientinformation form. !

 

Name:

Chief complaint or reason for visit:

patient history form.  

PRESENT ILLNESSES (i.e. high blood pressure, diabetes, sleep apnea restless legs, bleeding problems, GERD, glaucoma, etc.) Date Onset  

HOSPITALIZATIONS

Date Reason

 KNOWN ALLERGIES ( food/meds)

And React ion __________________________________

__________________________________

__________________________________

__________________________________

__________________________________

 

PRESENT MEDICATION & dose

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

PAST ILLNESSES

Yes No � � Tuberculosis � � Cancer � � Epilepsy � � Rheumatic Fever � � German Measles � � Jaundice � � Blood Clot � � High Blood Pressure � � Anemia Blood Disease � � Sleep Apnea � � Asthma � � Severe Cramps, Menses � � Freq. Vaginal Infection � � Freq. Bladder Infection � � Peptic Ulcer � � Gout � � Alcohol � � Heart Disease � � Arthritis � � Stroke � � Diabetes � � Bleeding Tendencies � � Other ______________

 

PREVIOUS SURGERY Yes No � � Breast. If yes, why? � � Hysterectomy. If yes, why? � � Tonsils � � Appendix � � Gall Bladder � � Hernia � � Tubal Ligation � � Caesarean Section � � D & C � � Eyes, Ears, Nose, Throat � � Skin Cancer � � Other  

FAMILY HISTORY Blood Clots ____________________ Thyroid Disease _________________ Diabetes _______________________ Tuberculosis ____________________ Breast Cancer___________________ Cancer ________________________ Epilepsy _______________________ Heart Disease ___________________ High Blood Pressure ______________ Glaucoma ______________________ Malignant Hyperthermia ___________ Other _________________________

SOCIAL HABITS

Drinking How much/Frequency Alcohol (current) � (past) � Aspirin � Coffee � Tea � Smoking (current) � (past) �

 

FEMALE ONLY

No. of Pregnancies Living Children Last Delivery Menses � Regular � Irregular Last Period Last PAP Smear Last Mammogram

 

Pat ient HIPAA Consent Form The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your personal medical and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect that privacy. When it is appropriate and necessary, we provide the minimum necessary information about treatment, payment or health care operations, in order to provide health care that is in your best interest. We are required to notify you if your PHI is ever breached.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of our personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form or have complaints about violations of your privacy rights please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

This office is regulated pursuant to the rules of the Board of Medicine as set forth in Rule Chapter 64B8, F.A.C.

Print Name

Signature Date

From Tampa:

6606 10th Avenue North

St. Petersburg, FL 33710

(727) 341-0337

I R E C T I O N S D

Take I-275 south over the Howard Franklin Bridge to exit 25 (38th Avenue North). Exit at 38th Avenue

North and go west to 66th Street North (approximately 3 miles). Turn left onto 66th Street and take 66th

Street down to 10th Avenue North. Make a right on 10th Avenue North and your first left into our

parking lot. We are located on the corner of 66th Street North and 10th Avenue North.

From Bradenton / Sarasota:

Take I-275 north over the Sunshine

Skyway Bridge to exit 24 (22nd

Avenue North). Exit at 22nd

Avenue North and go west to 66th

Street (approximately 3.5 miles).

Turn left onto 66th Street North and

take 66th Street down to 10th

Avenue North. Make a right on

10th Avenue North and your first

left into our parking lot. We are

located on the corner of 66th Street

North and 10th Avenue North.

From Clearwater:

Take Route 19 South to 22nd

Avenue North. Make a right onto

22nd Avenue North and take 22nd

Avenue to 66th Street North. Turn

left onto 66th Street North and take

66th Street down to 10th Avenue

North. Make a right on 10th

Avenue North and your first left

into our parking lot. We are located

on the corner of 66th Street North

and 10th Avenue North.

www.rehnkemd.com