Patient Registration Form

I hereby state that all the facts or information stated herein, including pertinent facts concerning my past medical and surgical. history, as well as any additional information that have been furnished to the treatment provider during my preoperative evaluation, are complete and correct.I certify that all information is correct to the best of my knowledge and I will not hold Dr. Mcf ate, MD nor his staff responsible for any errors or omissions that I have made on this form. The treatment provider has explained, in terms clear to me, the effect and nature of the procedure(s) to be performed , foreseeable risks involved and alternative treatment methods.I know that the practices of medicine, cosmetics, and lasers are not exact sciences and therefore medical professionals cannot guarantee exact results. I acknowledge that no guarantee or assurance of exact results has been made by anyone regarding the procedure(s) which I have requested and authorized. I have been advised that the goal and results of the procedure(s) that I have requested m ay not live up to my expectations or to the goals that have been established .

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

EMERGENCY CONTACT: RELATIVE OR FRIEND NOT LIVING WITH YOU

SPOUSE OR PARENT/GUARDIAN INFORMATION

Medical History:

Past Surgeries/Hospitalized (if none, please write none):

Family History (please check all that apply)

Please list all drug allergies (check none if none)

Please list your current medications (check none if none)

Social History

Do you drink alcohol or have a history of drinking alcohol?

Do you use any illegal drugs or have a history of using illegal drugs?

Do you have any sexually transmitted diseases or have a history of sexually transmitted disease?

Do you smoke cigarettes or cigars or have a history of smoking?

Wellness questions:

General:

Genito-Urinary:

Gastrointestinal:

Eyes, Ears, Nose, Throat:

Muscle, Bone, Joint

Respiratory:

Women's Health

By signing below, I, (Please input Name below) authorize Dr. Mcfate/ Precision Plastic Surgery and/or his/their representative(s), to take photographs, slides or videotapes of me or parts of my body showing before and after results of procedure(s). In addition, I authorize the use of these images, without compensation to me, to be used in the office, for office seminars, on websites owned by or operated on behalf of Precision Plastic Surgery for prospective patients, in print advertisements, medical presentation, articles, and on television. (This acknowledgement does not pertain to photographs, slides, or videotapes required for medical charts and/or records.)

I understand that:

1. Such photographs, slides or videotapes may be published by Dr. McFate/ Precision Plastic Surgery in any print, visual, or electronic media including, but not limited to, medical journals and textbooks, scientific presentations and teaching courses, and Internet web sites, for the purpose of informing the medical profession or the general public about plastic surgery methods. I understand that such uses may also include marketing on the behalf of Dr. McFate, for which Dr. McFate may receive direct or indirect remuneration.
2. I will not be identified by name in any of the media described above; however, I also understand that in some circumstances the photographs, slides or videotapes may display features that identify me.
3. I have the right to revoke this authorization in writing at any time. If I decide to do so, I must present my written revocation to Sarah Schneider (Privacy Officer). A revocation I shall not affect any release of information made prior to revocation in reliance upon this authorization.
4. I may refuse to sign this authorization without such refusal affecting the medical treatment I receive from Dr. McFate/ Precision Plastic Surgery
5. The information disclosed under this Authorization, or some portion thereof, is protected by state law and/or the federal Health Information Portability and Accountability Act of 1996 ("HIPAA"). Any disclosure of information carries with it the potential for an unauthorized secondary disclosure and the information may not be protected by applicable federal and/or state confidentiality rules.
6. A copy of this Authorization is valid as the original. I may inspect or copy information to be used or disclosed under this authorization, as provided by federal and/or state law.

I release and discharge Mcfate/ Precision Plastic Surgery from all photographic liability, including photographic: liability for negligence that in any way arises out of any and all rights that I may have or may have had in the photographs, slides or videotapes of me that I have authorized to be used and disclosed in this Authorization and any claim that I may have had relating to such use and disclosure of those photographs, slides or video tapes of me, including any claim for payment in connection with any distribution or publication of them in any medium.This Authorization is made as a voluntary contribution in the interest of public education and I certify that I have read this Authorization and Ref.ease carefully and fully understand its terms.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Contact Numbers

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

When necessary for us to contact you regarding health information, please indicate (in order of preference) the phone numbers we may use. please check yes or no if we can leave a detailed voicemail with medical information

HIPAA Privacy Authorization Form, I (Please input Name below) hereby authorize Precision Plastic Surgery to release any and all medical information and test results that pertain to me, to the following individuals.

I authorize Precision Plastic Surgery to contact the individual(s) listed above to convey any pertinent information to me. in the event that I am unable to be reached by the facility.I understand that I may revoke/cancel this authorization by notifying Precision Plastic Surgery in writing of my intent to revoke authorization or change the name(s) of the individuals to whom information is to be released.

Policies & Procedures

Any and all costs for surgical and/or nonsurgical procedures must be paid in full at the time of services rendered, unless otherwise noted

Refunds are not permitted.

I understand that I will be charged a fee of $30.00 for any returned checks or insufficient payments.

we will keep you informed of any outstanding balances that could occur. Any balance not paid by 60 days after the service date will be forwarded to our collection's agency. In the case of default of payment, you will be responsible for any collections cost or reasonable attorney fees incurred to satisfy this account.

A non-refundable deposit of $500 is required to confirm and hold the date of surgery. Local procedures require a non-refundable deposit of $250 to confirm and hold the date of your procedure.

APPOINTMENT NO SHOW POLICY

Precision Plastic Surgery requires a credit card on file and consultation fee of $100 for reservations with Dr. McFate. Fees will be applied to services rendered and will not be refunded for any reason. Should you not attend your scheduled appointment, fees will be considered a "no show" fee and will not be available as credit for services.

Precision Plastic Surgery requires a credit card on file to book appointments. Consultation fee is $100 and nonrefundable. You may apply this fee towards your surgery.

Also, please note that patients who arrive late 15 minutes or more for any appointment , may be asked to reschedule depending upon provider availability.

FINANCIAL POLICY

The surgeon and implant fees are to be paid in full two weeks prior to surgery. Forms of payment accepted : Cash,Personal Check,Money Order or Cashier's Check and Credit Card (Care Credit, Mastercard and Visa,(Discover and American Express may have processing fees that apply). To provide you with the best scheduling options, it is important that we follow the policies below.

Scheduling of Surgery

A non-refundable deposit of $500 is required to confirm and hold the date of surgery/secure your estimate of surgical fees.

Rescheduling or Cancellation of Surgery

The fee for cancellation or rescheduling withi two weeks of surgery is 25% of surgeon's fee.
The fee for cancellation or rescheduling within 48 hours of surgery is 50% of the surgeon's fee.

Payment of Surgery

As mentioned above, the surgeon and implant fees are to be paid in full two weeks prior to surgery. (see list of accepted payment). The facility and anesthesia fees are to be paid as directed by the surgical facility. Surgeon's pricing will expire 30 days from the date of the original surgical cost analysis. Facility and anesthesia pricing expire 10 days from the date pricing is give.*Refunds to a credit card will have a 10% processing fee on charges of $1,000 or .more and 5%processing fee on charges $100 up to $1,000 Additional financing charges may apply with Care Credit, Alpheon, or Medloan. *these fees with be assessed accordingly*

Pathology/ Lab work is not covered by Precision Plastic Surgery. This is an additional outside cost from all other quoted fees. You may provide your insurance information for anyLaboratory fees. COVID-19 Testing is patients' respons ibility along with any other labs ordered by Dr. McFate.

REVISIONARY SURGERY POLICY

When it comes to revisions, although good results are expected after plastic surgery, guarantees cannot be made regarding your outcome. Because of factors outside the surgeon's control, surgical revision may be required.This does not necessarily mean that your surgery was unsuccessful, or you would have done better with another surgeon. The reasons for suboptimal results may include the following:

• A person's inherent poor healing ability. For example, they form keloid scars or bad scars, irrespective of the plastic surgical closure
• Environment or lifestyle issues such as smoking, alcohol, or drug use, or excessive sun exposure will negatively impact the result
• Failure to comply with post-operative instructions including activity restrictions or usage of compression garments
• Failure to protect the surgical site
• Poor skin tone or severe skin laxity which can lead to recurrent sagging or tissue stretch and thinning
• Weight fluctuation or pregnancy after surgery
• Gravitational effects
• Poor circulation which can lead to delayed healing, open wounds, or skin lossMetabolism of underlying suture material with suture infections or suture spitting
• Metabolism of underlying suture material with suture infections or suture spitting.

In our practice, if a surgical revision is advised, surgeons fee may be discounted for any revisionary procedure, the patient is always financially responsible for all outside charges including operating room fees, anesthesia fees, implant or garment fees,and supply fees.

Acknowledge of revisionary surgery policy

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Office Policy

New Prescriptions and Medication Refills: If you receive a prescription duringyour visit today,please allow 24 hours for the prescription to be filled unless advised otherwise. Please contact your pharmacy first to check the status of your prescriptio n before contacting our office. Your pharmacy may have their own protocol for time to process prescriptions once received.

Patient Paperwork: If you have patient paperwork that needs to be completed (FMLA, Disability forms, Misc. forms,etc.) Once you have filled out your portion of the paperwork,the requested paperwork will be completed and returned within 15 business days. Please note there are fees associated with paperwork completion. $50.00 request fee. $20 Notary fee,and $75 cents for each additional page.

Procedure Scheduling: For any procedure ordered by Dr. McFate, please allow 5-7 business days for our Office Manager to contact you. Within this time frame, our office will be reaching out to your insurance company to obtain prior authorization,if needed. If prior authorization is required, the procedure will be scheduled once authorization is obtained. Once prior authorization is obtained,our office will reach out to you directly to coordinate a date and time for your procedure. If your insurance does not require prior autho rizat ion,our office will ca ll you to schedule once benefits are obtained.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Authorization to receive historical prescription history

I hereby authorize Dr. McFate and his affiliated staff to electronically retrieve my external prescription history. I understand that I can revoke my permission at anytime by giving written request to my provider.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.

We realize that these laws are complicated, but we must provide you with the following important information.Use and disclosure of your health information in certain special circumstances

THE FOLLOWING CIRCUMSTANCES MAY REQUIRE US TO USE OR DISCLOSE YOUR HEALTH INFORMATION:To public health authorities and health oversight agencies that are authorized by law to collect information.Lawsuits and similar proceedings in response to a court or administrative order.If required to do so by a law enforcement official.When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.We will only make disclosures to a person or organization able to help the threat. If you are a member of U.S.or foreign military forces {including veterans) and if required by the appropriate authorities.To Federal officials for intelligence and national security activities authorized by law.To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.For Workers Compensation and similar programs.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.

You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations.Additionally, you have the right to request that we restrict our disclosure or your health information to only certain individuals involved in your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

You have the right to inspect and obtain a copy of the health inform at ion that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Precision Plastic Surgery,4701Bee Cave Road,Suite 106,Austin,Texas 78746,(512} 270-8047.

You may ask us to amend your health information if you believe it is incorrect or incomplete, and if the information is kept by or for our practice.To request an amendment, your request must be made in writing and submitted to Precision Plastic Surgery,4701 Bee Cave Road,Suite 106, Austin, Texas 78746,(512) 270-8047.You must provide us with a reason that supports your request for amendment.

Right to a copy of this notice. You are entitled to receive a copy of this notice of Privacy Practices.You may ask us to give you a copy of this notice at any time.To obtain a copy of this notice, contact Precision Plastic Surgery at (512) 270-8047.

Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services.To file a complaint with our practice, contact Precision Plastic Surgery at (512) 270-8047.All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or Permitted by applicable law.

If you have ally questions regarding this notice or our health information privacy policies, please contact Precision Plastic Surgery at (512) 270-8047.

To our patients.This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and* Accountability Act of 1996 (HIPAA).

Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand hat form my medical information to be shared with any family member, they must be designated as such below. I understand that I am entitled to receive a copy of this document.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.