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 Lift [Internal Mastopexy] Breast Lift [External Mastopexy] Removal & Replacement of Breast Implants [Explanation of Breast Prosthesis with Secondary Augmentation Mammoplasty] Removal of Breast Implants [Capsulectomy with Explanation of Breast Prosthesis] Removal of Breast Implants with Internal Mastopexy and Fat Grafting Breast Reduction [Reduction Mammaplasty] Male Breast Reduction [Reduction of Gynecomastia]

▪ BREAST – RECONSTRUCTIVE

Biopsy or Removal of Breast Lump [Breast Biopsy or Lumpectomy] Delayed Reconstructive Breast Surgery Without Breast Implants [Autologous Fat Grafting] Breast Reconstruction with Implant Nipple Reconstruction [Nipple-Areolar Complex Reconstruction] Removal of Breast Tissue [Subcutaneous Mastectomy] Revision of Breast Surgery

▪ 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] Z-Plasty Technique Fat Grafting Nano Fat Grafting to Deep Dermis

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 Botox Xeomin Jeuveau Juvederm Voluma Versa Volbella Vollure Belotero Radiesse Restylanne Silk NON-SURGICAL FACIAL REJUVENATION Kybella PDO Threads

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 Accreditation of Ambulatory Surgery Facilities (AAAASF). All professional staff are ACLS certified.

Robert D. Rehnke, M.D.,

. . . . . . . . . . . . . . . . . . . . . . . . . . . (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 Implant Removal Breast Reduction Facial Rejuvenation

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

!

Revision date [8/1/19] 1

M . D .

The Center for Surgical Excellence

Notice of Privacy Practices for Protected Health Information HIPAA

I. Our Commitment to You Robert D. Rehnke M.D. and The Center for Surgical Excellence are committed to maintaining the privacy of your health information. During your treatment with us, physicians, nurses, and other personnel may collect information about your health history and your current health status. This notice explains how that information, called “Protected Health Information” (PHI) may be used and disclosed to others. The terms of this notice apply to health information produced or obtained by Robert D. Rehnke M.D. and The Center for Surgical Excellence.

II. Our Legal Duties The HIPAA Privacy Law requires us to provide this notice to you regarding our privacy practices, our legal duties to protect your private information and your rights concerning health information about you. We are required to follow the privacy practices described in this notice whenever we use or disclose your protected health information (PHI). Other companies or persons that perform services on our behalf, called Business Associates, must also protect the privacy of your information. Business Associates are not allowed to release your information to anyone else unless specifically permitted by law.

III. Permitted Uses & Disclosures of Your Medical Information The HIPAA Privacy Law permits Robert D. Rehnke M.D. and The Center for Surgical Excellence to make uses and disclosures of your health information for purposes of treatment, payment and health care operations.

• Treatment: We will use and may share health information about you for your health care and treatments. Except in emergency circumstances, we will make a “good faith effort” to get your permission prior to making disclosures outside The Center for Surgical Excellence for treatment purposes.

• Payment: We may use and disclose health information about you to obtain payment for the care and services that we have provided to you.

• Health Care Operations: Members of our staff may review health information in your record in order to assess the care and outcomes in your case and others like it. We need to do this so we can continually improve and ensure the highest quality of care.

• People Assisting in Your Care: The Center for Surgical Excellence may disclose essential health information to people such as family members, relatives, or close friends who are helping care for you. We will disclose information to them only if these people need to know the information to help you. Generally, we will ask you prior to making disclosures if you agree to such disclosures.

• Research: Federal law permits The Center for Surgical Excellence to use or disclose health information about you for research purposes. We may disclose your information if we have your written authorization to do so. We will make a “good faith effort” to acquire your permission or rejection to participate in any research prior to releasing any protected information about you.

Revision date [8/1/19] 2

IV. Your Rights Regarding Health Information We Maintain About You

• You have the right to inspect and receive a copy of your PHI.

• If you believe that any health information, we have about you is incorrect or incomplete, you have the right to ask us to change the information, for as long as The Center for Surgical Excellence maintains the information.

• You have the right to request a restriction or limitation on certain uses and disclosures of your health information.

To request restrictions, you must make your request in writing to Robert D. Rehnke M.D. and The Center for Surgical Excellence In your request, you must tell us:

§ What information you wish to limit § Whether you wish to limit our use, disclosure, or both § To whom you want the limits to apply – for example, if you want to prohibit disclosures for

insurance payment, health care operations, for disaster relief purposes, to persons involved in your care, or to your spouse.

You or your personal representative must sign it.

• You have the right to receive an accounting of certain disclosures of your PHI. Your accounting request must be in writing and signed by you or your personal representative and submitted to Robert D. Rehnke M.D. and The Center for Surgical Excellence. Your request must specify the time in which the disclosures were made. These disclosures may not go back further than six years from the date of the request.

• You have the right to request that we communicate with you about medical matters in a confidential manner or at a specific location.

• You have the right to a paper copy of this Notice of Privacy Practices even if you have agreed to receive the notice electronically. You may ask us to give you a copy of this notice at any time.

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