Fees & Financing

All fees will be discussed freely in advance by the office staff and they will assist you with financing if desirable. Insurance companies do not cover the cost of cosmetic surgery.  In compliance with suggestions adopted by the American Society of Plastic Surgeons, it is customary for the patient to pay all fees for cosmetic surgery prior to the desired operation.   This insures that the patient is sincere in her motivation and can afford the surgery, thus creating a better patient/physician relationship.  A non-refundable deposit will be required to secure your desired surgery date.   The remainder of the fees must be paid prior to the surgery, usually at the time of the preoperative visit, but no later than one week before surgery. Additional fees are also required for the implants, laboratory tests, surgical facility fees, and the anesthesiologist.

If additional surgical procedures become necessary, additional facility, laboratory, anesthesia, implant costs and professional fees will be incurred. The surgical facility and anesthesiologist fees quoted will be based on our best faith estimate; the final fee may vary as these fees are based on surgical time, and it is not always possible to predict exactly how long a procedure will take to complete.   It is important that you understand that the patient is responsible for all costs associated with all secondary surgical procedures or for the treatment of any complications that may arise as a result of this elective surgery.

IMPLANT PATIENT REVIEW ADVISORY

The following items should be discussed with the patient, and the patient should initial each space, prior to the performance of an implant procedure:

GENERAL INFORMATION

1. Description of alternative operative procedures, preferred technique and why
2. Available methods of anesthesia and discussion of surgeon's preference
3. Post-operative recovery time and limitation of normal activities
4. Long-term limitations on individual lifestyles, if any

ANTICIPATED OUTCOME

1. Anticipated size, shape and aesthetics
2. Constraints of individual's anatomy
3. Complete correction of asymmetry impossible
4. Location and probable nature of incisional scars

THE IMPLANTS

1. Types available
2. Advantages/disadvantages
3. Type to be used and why

INHERENT RISKS

1. Inherent risk assumed by patient as part of procedure
2. Nature and unpredictability of capsular contracture and its physical effects
3. Treatment options of complications and risks
4. Possibility of need for future implant replacement
5. Rare and unsubstantiated, but possible relationship to connective tissue disorders

COMPLICATIONS

1. Capsular contractures
2. Infection
3. Bleeding requiring return to the Operating Room (Hematoma)
4. Excess or obvious scar
5. Changes in nipple sensation
6. Chronic pain
7. Asymmetries significant enough to require reoperation

ECONOMICS

1. Costs of procedure

Even though the risks and complications cited occur infrequently, these are the ones that are particularly peculiar to the operation; other complications and risks can occur but are even more uncommon.

Patient wants these described _____                Patient does not want-these described _____

The practice of medicine and surgery is not an exact science. Although good results are expected, there cannot be any guarantee or warranty, expressed or implied, as to the results that may be obtained.

Additional Comments:___________________________________________
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Pre and post-op photos will be taken of the treatment site for record purposes. I understand that these photos/videos will be the property of the attending physician.  I do____, do not ___ agree to allow these pictures to be used for publication, teaching purposes or the practice web site. If I agree, I understand that my name will be kept confidential and protected.

IF YOU HAVE ANY QUESTIONS, DO NOT HESITATE TO CALL THE OFFICE DURING BUSINESS HOURS (949-888-9700) OR AFTER HOURS, CALL YOUR SURGEON  - DR BUNKIS CELL PHONE NUMBER IS  (949) 500-8856, OR REGISTERED NURSE, TRACEY PRESCOTT’S NUMBER IS (949) 338-6072.     

WITH AN EMERGENCY THAT REQUIRES IMMEDIATE ATTENTION, CALL 911 BUT PLEASE HAVE YOUR FAMILY NOTIFY DR. BUNKIS OF ANY PROBLEMS YOU MAY HAVE!

I, ____________________________________________, certify that I have read and understand the “Implants” information sheets dated March 2008, that my surgeon has answered all of my questions to my satisfaction, that I understand the alternatives and risks, accept the risks and that I give my fully informed consent for this procedure. 

Patient Signature_______________________ Date__________________

I certify that I, or a member of my staff has discussed all of the above with the patient and have offered to answer any questions regarding the procedure. We believe that the patient fully understands the explanation and answers.

Surgeon’s Signature_____________________ Date_________________

Initial if copy requested/given to patient____________________________ Copy placed in chart __________________________________________

Copyright 11/87 Last revised 03/08
Juris Bunkis, M.D., F.A.C.S.