Please be advised that by providing this form for you to contact our office(s), we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into this portal. Our office will follow up with you within 24 to 48 hours business hours. This form of communication is not intended for acute, emergency, or lift- threatening health conditions. If you believe you are having a health emergency, contact 911 or go to your nearest emergency department.
Patient Center Forms, Brochures, Articles, FAQ, Pre and postoperative guidelines & Financing Applications!
Welcome to our patient center! Because we are Joint Commission Accredited we require more than the average Office does in paperwork . While this may be cumbersome and seem like a burden to you, we value our commitment to outstanding and safe surgical care. Dr Jeneby has spent almost 1000 hours becoming accredited for the sole purpose of providing a safe environment for you and your loved one. Please enjoy the patient Center forms, brochures and downloads!
PDF Forms
(All need to be completed prior to visit and brought to the center or this could delay your appointment)
General Forms
Post Op General
General Post-Op Instructions
Patient Demographics
History and Physical
Patient Checklist
Binding Non-Assignment
Medical Records Release
COVID-19 RISK
Hepatitis and Human Immunodeficiency Virus (HIV) Testing
“Off-Label” Use of XXXXX
OUT-OF-NETWORK FINANCIAL RESPONSIBILITY
Patient Picture and Video Release
Telemedicine
Initial Learning Assesment
Media Release
Cash or Finance Agreement
Financial Lawsuit and/or Dispute
Patient Acknowledgement
Patient’s Bill of Rights
HIPAA Notice of Privacy Practices
Disclosure Information
Body
Abdominoplasty
Body Lift Surgery
Brachioplasty
Buttock Augmentation
Buttock Augmentation by Fat Transfer
Buttock Augmentation with Implants
Buttock Lift Surgery
Calf Implant
Fat Transfer – Hand
Fat Transfer, Grafts, and Injections
Fat Transfer, Grafts, and Injections – Breast
Fat Transfer, Grafts, and Injections – Face
Free Myocutaneous Flap Surgery
Myocutaneous Flap Surgery
Labiaplasty
Liposuction
Liposuction/Smart Lipo
Medial Thigh Lift Surgery
Migraine Surgery
Mini-Abdominoplasty Surgery
Panniculectomy Surgery
Vaginoplasty and Perineoplasty
Buttock Implant/Fat Grafting
Thigh Lift
Tummy Tuck
Weight Loss Program New Patient Packet
Breast
Breast Augmentation With Silicone
Breast Augmentation With Saline Filled Implants
Breast Augmentation With Larger Implants Than Recommended
Breast Implant Capsules
Breast Implant Removal
Breast Reconstruction with Latissimus Muscle Flap
Breast Reconstruction with DIEP Flap
Breast Reconstruction with Tissue Expander
Breast Reconstruction with TRAM Flap
Breast Exercises
Breast Lift
Breast Reduction
Gynecomastia Surgery
Nipple Reconstruction Surgery
“Off Label” Use of ADMs
Placement of Breast Implant Following Breast Reconstruction by Tissue Expansion
Skin
Autologous Tissue Graft
Botulinum Toxins:Botox®, Dysport®, Xeomin®, Jeaveau® Neurotoxins
Chemical Skin Peels and Treatments
Facial Volume/Filler Injection
Hyaluronic Acid Filler Injection
Kybella® – Deoxycholic Acid Injection
Laser Skin Resurfacing Procedures
Repairing Skin Defects with Skin Flaps
Scar Revision Surgery
Sclerotherapy
Skin Lesion Removal
Skin Graft Surgery
Soft Tissue Filler Injection
Renuvion Consent
PDF Forms (Spanish)
Formularios Generales
Formulario 1:RIESGOS GENERALES DE LAS CIRUGÍAS
Pecho
Formulario 2:Mamoplastía de aumento con implantes de solución salina
Formulario 3:Mamoplastía de aumento con implantes de gel de silicona
Formulario 4:Aumento de Seno con un implante más grande que el recomendado por el Dr./Dra.
Formulario 5:Tratamiento quirúrgico del encapsulamiento de implantes de seno, incluso capsulotomía, capsulorrafia y capsulectomía
Formulario 6:Ejemplo de lista de verificación de decisiones del paciente
Formulario 7:Extracción de implantes mamarios
Formulario 8:Levantamiento de senos (mastopexia)
Formulario 9:Reconstrucción de senos con colgajo del músculo dorsal ancho
Formulario 10:Reconstrucción de senos con colgajo DIEP
Formulario 11:Reconstrucción de senos con extensor de tejido
Formulario 12:Reconstrucción de senos con colgajo TRAM
Formulario 13:Reducción de senos
Formulario 14:Cirugía de ginecomastia
Formulario 15:Cirugía de reconstrucción de pezones
Cuerpo
Formulario 16:Cirugía de abdominoplastia (reducción de abdomen)
Formulario 17:Cirugía de lipoescultura
Formulario 18:Braquioplastia
Formulario 19:Cirugía de levantamiento/aumento de glúteos
Formulario 20:Procedimientos para lipotransferencia, lipoinjertos e inyecciones – Glúteos
Formulario 21:Procedimientos para lipotransferencia, lipoinjertos e inyecciones – Senos
Formulario 22:Procedimientos para lipotransferencia, lipoinjertos e inyecciones – Rostro
Formulario 23:Labioplastia
Formulario 24:LIPOSUCCIÓN
Formulario 25:Cirugía de levantamiento de muslos intermedios
Formulario 26:Cirugía de mini abdominoplastia
Rostro
Formulario 27:Cirugía de blefaroplastia
Formulario 28:Cirugía de levantamiento de cejas
Formulario 29:Cirugía de estiramiento facial (ritidectomía)
Formulario 30:Cirugía de otoplastia
Formulario 31:Cirugía de estiramiento facial parcial (ritidectomía)
Formulario 32:Cirugía de rinoplastia
Formulario 33:Cirugía de rinoplastia de punta nasal
Cutis
Formulario 34:Toxinas botulínicas – neurotoxinas Botox®, Dysport®, Xeomin®
Formulario 35:Exfoliaciones químicas y tratamientos de la piel
Formulario 36:Inyección de relleno de volumen facial
Formulario 37:Inyección de relleno de ácido hialurónico
Formulario 38:Kybella® – Inyección de ácido desoxicólico
Formulario 39:Procedimientos de rejuvenecimiento con láser de la piel
Formulario 40:Cirugía de corrección de cicatrices
Formulario 41:Escleroterapia
