| The determination of how many Follicular Units are to be transplanted during your procedure is based upon the information discussed during your consultation and subsequently referenced to in your consultation letter. This information includes your approximate donor density, scalp laxity (looseness) and the personalized plan relating to your goals and objectives. Based on this information, you understand that:
(i) your exact donor density and scalp laxity cannot be determined until the procedure has begun, and
(ii) although you and the physician agree on the specific number of Follicular Units to be transplanted in accordance with the physician's best medical judgement, it may not be possible to achieve the exact number of Follicular Units scheduled. The physician will make every reasonable effort to achieve the number of grafts scheduled.
HOWEVER, should the physician determine at the time of surgery that he is able to harvest additional Follicular Units than originally agreed to, prior to preoperative sedation; you may request the physician to harvest and transplant such additional Follicular Units by signing where indicated on this Agreement.
I fully understand the above and request the physician to harvest additional follicular units as, in the physician's judgment, is medically safe to do so.
I hereby elect one (1) of the following options:
____ A. YES, I request the physician to transplant as many additional Follicular Units as safely possible which are appropriate to the recipient site.
____ B. YES, I request the physician to transplant additional Follicular Units if safe and appropriate. I wish to limit the number of additional Follicular Units to _________
_____ C. NO, I request the physician to remain as close as possible to the original number of Follicular Units scheduled for this procedure .
I,_________________________________________________, agree to be responsible for the payment of the additional Follicular Units transplanted during my procedure. I will pay the same rate per Follicular Unit as indicated in my financial summary. I understand that payment is to be made on the same day of the procedure by personal check, credit card, travelers check, or cash, unless other financial arrangements have been made and agreed to in advance.
Patient's Signature: ___________________________ Date ____________ Time____________
IHTI Witness: _________________________________ Date ____________ Time ___________
METHOD OF PAYMENT: Personal/Cashiers/Travelers Check: _____ Credit Card: ____ Cash:____ |
