Plastic Surgery Institute of Dayton Forms and Policies

Patient Satisfaction Survey

• New Patient Forms

  1. Dear Cosmetic Patient – PLEASE READ
  2. Dear Patient – PLEASE READ!
  3. Receipt for HIPAA Notice
  4. Privacy Policy
  5. Insurance Disclaimer
  6. Payment Policy
  7. Written Directions
  8. Preparing for your Nurse Visit

• Opioid Analgesic Counseling Guide

• Post-Operative Instructions

  1. Abdominal Surgery
  2. Blepharoplasty
  3. Body Lift, Thigh Lift, Butt Lift
  4. Brachioplasty
  5. Breast Reconstruction at the Hospital
  6. Breast Reconstruction
  7. Breast Reduction
  8. Breast Surgery
  9. Drainage Record
  10. Facial Surgery
  11. Hand Surgery
  12. How to Care for your JP drain
  13. Laser Resurfacing
  14. Liposuction/Fat Grafting
  15. Lovenox Injection
  16. Mentor Warranty
  17. Minor Surgery
  18. Nasal Surgery
  19. Nipple Reconstruction
  20. Scopolamine Patch

• Pre-Surgery Forms

  1. Patient Rights
  2. Policy and Procedure on Advanced Medical Directives
  3. Pre-Op Instructions

• Ambit Pump Instructions

• Surgery Consents

  1. Abdominoplasty
  2. Augmentation Mammaplasty Saline
  3. Augmentation Mammaplasty Silicone
  4. Augmentation Mammaplasty with Larger Implant than Recommended
  5. Blepharoplasty
  6. Body Lift Surgery
  7. Brachioplasty
  8. Breast Implant Removal
  9. Breast Lift Mastopexy
  10. Breast Reconstruction with DIEP Flap
  11. Breast Reconstruction Latissimus Muscle Flap
  12. Breast Reconstruction with Tissue Expander
  13. Breast Reconstruction with TRAM Abdominal Muscle Flap
  14. Breast Reduction
  15. Brow Lift Surgery
  16. Buttock Lift Surgery
  17. Capsulectomy with Breast Implant Replacement Using Saline Filled Implants
  18. Capsulectomy with Breast Implant Replacement Using Silicone Gel Filled Implants
  19. Capsulotomy-Saline replace
  20. Capsulotomy-Silicone
  21. Carpal Tunnel Release Surgery
  22. Chemical Skin Peels and Treatments
  23. Cutaneous Skin Flap Surgery
  24. Extensor Tendon Repair Surgery
  25. Facelift Surgery
  26. Facial Implant Surgery
  27. Fat Transfer – Breast
  28. Fat Transfer – Buttock
  29. Fat Transfer – Face
  30. Fat Transfer – Hand
  31. Fat Transfer Procedures
  32. Flexor Tendon Repair Surgery
  33. Ganglion Cyst Surgery
  34. Gynecomastia Surgery
  35. Hepatitis HIV Test
  36. Labiaplasty
  37. Laser Resurfacing Procedures of Skin
  38. Liposuction
  39. Medial Thigh Lift Surgery
  40. Mini Abdominoplasty
  41. Nasal Injury Repair Surgery
  42. Nipple Reconstruction
  43. Otoplasty
  44. Panniculectomy
  45. Partial Facelift Surgery Rhytidectomy
  46. Placement of Breast Implant Following Breast Reconstruction by Tissue Expansion
  47. Rhinoplasty
  48. Scar Revision Surgery
  49. Septoplasty
  50. Skin Cancer Reconstruction
  51. Skin Cancer Surgery
  52. Skin Graft Surgery
  53. Skin Lesion Tumor Surgery
  54. Tenolysis Surgery
  55. Tip Rhinoplasty
  56. Trigger Finger

• Disclosure Forms

  1. MENTOR MemoryGel Patient Checklist

• General Discharge Instructions

  1. General Discharge Instructions
  2. General Dishcarge Instructions for Brachioplasty
  3. General Discharge Instructions for Nose Surgery
  4. General Discharge Instructions for Liposuction
  5. General Discharge Instructions for Laser Resurfacing
  6. General Discharge Instructions for Dr. Schmidt Breast Surgery
  7. General Discharge Instructions for Dr. Hedrick Breast Surgery
  8. General Discharge Instructions for Dr. Fox Breast Surgery
  9. General Discharge Instructions for Breast Reduction
  10. General Discharge Instructions for Blepharoplasty
  11. General Discharge Instructions for Abdomen Sx
  12. General Discharge Instructions Facelift, Forehead, Cervicoplasty

• Patient Portal

  1. Existing User Login
  2. New User Login

• Cosmetic Consultation Policy

• No Show and Same Day Cancel/Reschedule Policy