Fees

All fees will be discussed freely in advance by the office staff. Financing may be arranged if desired. Your insurance company may cover a part of the fee. Payment of all fees, however, is the patient's responsibility; all fees are due prior to surgery. If requested, the office staff will assist you with forms, but recovery of any insurance benefits is between you and your insurance company. Insurance companies never pay for the entire fee and never pay for nasal operations which are solely designed to improve your appearance.

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 more than one week before surgery. Additional fees are also required for 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.

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 “Protruding Ear Pin Back” information sheets dated October 2008, that my surgeon has answered all of my questions to my satisfaction, and that I give my informed consent for this procedure. Patient/Parent Signature ___________________________ Date_______________ Witness_________________________________________ 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 10/08
Juris Bunkis, M.D., F.A.C.S.