FTM Transgender Preop Packet rev21113-1.pdf

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P L A S T I C & R E C O N S T R U C T I V E S U R G E R Y

FTM Transgender Preop Checklist

Here is a list of things you must have done prior to your surgery. It is your responsibility to make

sure all of these documents are forwarded to our office by your healthcare providers. We

have enclosed prescriptions for medical clearance, lab work, and mammogram studies.

-YOU MUST STOP TAKING MEDICATIONS WHICH ARE STIMULANTS (SUCH AS ADDERALL) AT LEAST

10 DAYS PRIOR TO YOUR SURGERY, AS THEY CAN INTERACT WITH THE ANESTHESIA

MEDICATIONS.

-IF YOU HAVE A LATEX ALLERGY OR WEIGH MORE THAN 300 LBS YOU MUST NOTIFY OUR OFFICE

IMMEDIATELY SO THAT SPECIAL ARRANGEMENTS CAN BE MADE. OTHERWISE, YOUR SURGERY

MAY CANCELLED WHEN YOU ARRIVE.

-IT IS VERY IMPORTANT YOU BE 100% HONEST AND INFORM US OF YOUR ENTIRE MEDICAL

HISTORY, AS WITHOLDING VITAL HEALTH INFORMATION CAN JEOPARDIZE YOUR SAFETY.

-YOU ARE REQUIRED TO HAVE SOMEONE WITH YOU THE DAY OF YOUR SURGERY AND TO STAY

WITH YOU DURING YOUR POSTOPERATIVE STAY TO ASSIST YOU.

-YOU ARE REQUIRED TO STAY IN TOWN FOR AT LEAST 7 DAYS AFTER SURGERY TO ASSURE YOU

WILL RECEIVE THE APPROPRIATE MEDICAL CARE FOR YOUR SURGERY.

-DO NOT BRING LUGGAGE TO OUR OFFICE DURING YOU APPOINTMENTS

Check off each line after you have confirmed we have received these REQUIRED documents

in our office:

Signed copy of the Financial Policy included in this packet.

Gender Therapist or Primary Care Physician Letter. We have included a

convenient form for your Therapist or Physician to fill out to serve as a letter of

reference for your chest surgery. Please send this back to us completed..

Medical Clearance (includes a physical examination by an M.D. or D.O. licensed

physician done within 30 days of the date of surgery)

Lab Work (done within 30 days of the date of surgery)

Mammogram (only if you are over 35 years of age or otherwise instructed to get a

mammogram by Dr. Garramone)

Digital Photographs of your chest emailed directly to Dr. Garramone

([email protected])

If you are having Mansculpture Liposuction of the thighs or hips, you will need to bring

spandex compression shorts for your postoperative care. We recommend

compression shorts by Underarmor, Champion, etc. The can usually be found in any

sports store. We will provide only an abdominal compression garment for you if you

are having Mansculpture of the abdomen and lovehandle regions.

We only allow photos and video recording during you postoperative dressing removal

(chest surgery reveal). No photos, video, or audio recording are allowed in our office

before surgery or at the Surgical Center. Please respect other people’s privacy and

do not photograph anyone else in our office.

A E S T H E T I C P L A S T I C S U R G E R Y I N S T I T U T E , P . A .

D r . C h a r l e s E . G a r r a m o n e

B o a r d C e r t i f i e d P l a s t i c & R e c o n s t r u c t i v e S u r g e r y

4725 SW 148th Ave, #202, Davie, FL 33330 Phone: (954) 752-7842 Fax: (954) 473-2454

E-mail: [email protected] Web: www.transgenderflorida.com

mailto:[email protected]

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**IMPORTANT** We recommend you wear compression socks while traveling to and

from our office to help reduce the risk of developing deep vein

thrombosis (DVT). You can purchase these from your local stores or

online. Patients traveling long distance of greater than 4 hours of

immobility are at greater risk for developing DVT.

It is important you ask your physician who prescribes Testosterone,

whether they would recommend you stop taking your testosterone

prior to surgery. It is not up to Dr. Garramone to decide on the safety of

stopping your Testosterone. DO NOT BRING YOUR LUGGAGE WITH YOU FROM THE AIRPORT TO OUR OFFICE.

WE DO NOT ALLOW LUGGAGE INSIDE OUR OFFICE DUE TO PREVIOUS DAMAGE

TO OUR OFFICE FROM PRIOR PATIENTS DISREGARD FOR PERSONAL PROPERTY.

Things to pickup for your recovery while staying in Florida: Sourdough Bread, Ginger Ale, Milk of Magnesia or Prune Juice, we recommend Benadryl or Zyrtec for itching, Baby Wipes, and Compression Stockings.

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Letter of Recommendation for the FTM Top Surgery® Procedure (Female to Male Gender Reassignment Chest Surgery)

We require a letter of recommendation or referral for the FTM Top Surgery® Procedure (Female to Male Gender Reassignment Chest Surgery). You may also have this form completed by your Physician or Therapist, to serve as a letter of recommendation for your chest surgery. This letter follows WPATH and Informed Consent guidelines. The organization and completeness of these letters provide Dr. Garramone an important degree of assurance that the mental health professional or primary care physician is knowledgeable and competent concerning gender identity disorders. World Professional Association for Transgender Health Standards of Care available at http://www.wpath.org/

Patient Legal Name:_________________________________________________ Patient Date of Birth:_________________________________________________ Patient Address:____________________________________________________ Patient Telephone Number:___________________________________________

Please Complete the following. Section A is required. Section B is recommended but not required. Section A (required):

Chest Surgery is the next step in the Transition Process (the criteria for surgery have been met) Patient is at least 18 years of age, or will be at the time of surgery (Dr. Garramone requires all patients be

over the age of 18 years to be eligible for surgery)

Section B (recommended): The Mental Health Professional or Primary Care Physician Documentation for Surgery Should Succinctly Specify:

Patient has a persistent, well-documented gender dysphoria or breast dysphoria Patient has the capacity to make a fully informed decision and to consent for treatment with surgery If significant medical or mental health concerns are present, they must be reasonably well controlled

(please attach separate letter describing the status) Hormone therapy is not a pre-requisite The Patient has general identifying characteristics as male, gender neutral, or gender variant. Results of the client’s psychosocial assessment, including any diagnoses (please attach separate letter

describing the status) The duration of the mental health professional’s relationship with the client, including the type of

evaluation and therapy or counseling to date (please attach separate letter describing the status) A brief description of the clinical rationale for supporting the patient’s request for surgery (please attach

separate letter describing the status if necessary) Informed consent has been obtained from the patient regarding understanding surgery and its impact The Physician or Therapist is available for coordination of care and welcomes a phone call to establish

this. (please attach separate letter describing)

I certify the above is true and correct, to the best of my knowledge, and have completed this form to serve as a recommendation and a referral for FTM Top Surgery® Procedure (Female to Male Gender Reassignment Chest Surgery) to be performed by Dr. Charles Garramone on the above mentioned patient. Physician or Therapist Signature:__________________________________________Date:__________________ Physician or Therapist Name:_____________________________________________ Office Address:________________________________________________________ Office Telephone:______________________________________________________

http://www.wpath.org/

Aesthetic Plastic Surgery Institute, PA

Dr. Charles E. Garramone

Plastic & Reconstructive Surgery

4725 SW 148th Ave, Suite 202

Davie, FL 33330

954-752-7842

Aesthetic Plastic Surgery Institute Financial Policy

We are dedicated to providing the best possible care for you, and we want you

to completely understand our financial policies. We reserve the right to change our financial policies at any time without prior

notification of the patient. 1. PAYMENT IS DUE THREE WEEKS PRIOR TO THE DATE OF SCHEDULED SERVICE unless arrangements have

been made in advance by our office. We accept Visa , MasterCard, Discover, American Express, and Cash. WE DO NOT ACCEPT PERSONAL CHECKS. We do not accept NO INTEREST financing plans.

2. Keep in mind that we do not accept any insurance plans nor will we submit any claims to your insurance company on your behalf. All surgery performed by Dr. Garramone is elective cosmetic surgery which is not covered by insurance.

3. It is illegal for you to file an insurance claim on our behalf and is considered fraud. If you file an insurance claim on our behalf without our written consent or attempt to present yourself as a representative of our practice, we will be forced to report the claim as a fraudulent claim which may impose a strict penalty according to law.

4. Dr. Garramone’s surgical fee quotes do not include lab work, pathology, cost of preoperative testing or consultations, cost of prescription medications, x-rays, or cost of postoperative garments. Dr. Garramone’s surgical fee applies only to his performance of your procedure. We will explain all Hospital fees, etc, during your consultation and all hospital and anesthesia fees must be paid to the hospital separately on the date of surgery. All financing will be assessed a 6% Administration fee from our office in addition to the amount financed. This is non-refundable.

5. I authorize Aesthetic Plastic Surgery Institute to release or obtain all medical records including Protected Health Information to and from additional parties, if necessary to settle a disputed charge for services provided. This includes Visa, MasterCard, Discover, American Express, Personal Checks, Cash payments, and financing payments.

6. If you have paid a consultation fee for elective non-insurance related services, this may be able to be applied toward your full cost of the proposed procedure, otherwise it is non-refundable.

7. If you are scheduling an elective procedure, a $500 non-refundable deposit is required to secure the date of the procedure and will be applied toward the cost of the surgery. If, within 2 weeks of the date of surgery, you try to reschedule your surgery for another date in the future, then you will be charged a $500 Cancellation Administration Fee and essentially lose your deposit. Certain administrative fees are not refundable due to practice costs and financing costs, and will vary from patient to patient and amount of costs.

8. All fees paid to Aesthetic Plastic Surgery Institute, PA are non-refundable, this includes fees for services performed, fees paid in advance as a part of a package or gift certificate, fees for skin care products, fees for seminars.

When you schedule your surgery, we are committing a large block of Dr. Garramone’s time and the time of 8-10 additional personnel at the surgical facility. We therefore, require a scheduling deposit to reserve your surgical date. We will only refund 65% of your total surgical fee, not including the non-refundable deposit, if the surgery is cancelled for any reason other than the following:

a. Dr. Garramone is unable to perform the surgery for any reason. b. The patient has medical indications to cancel surgery. Dr. Garramone will

consult with your treating physician to determine the appropriateness of medical indication for cancellation.

I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice without prior notification to me. I further understand I am responsible for payment of a medical service or medical services, and I am not purchasing a returnable product or a result and therefore cannot receive refunded monies for medical services already provided.

________________________________________________ ______________

Signature of patient (or responsible party, if minor) Date

__________________________________________

Please print the name of the patient

Medications to Avoid Before and After Surgery

If you are taking any medications on this list, they should be discontinued 14-21 days priorto surgery and only TYLENOL should be taken for the pain. All other medications that youare currently taking must be specifically cleared by Dr. Garramone prior to surgery. It isabsolutely necessary that all of your current medications be specifically cleared by Dr.

Garramone and nursing staff. Common medications that are taken are Aspirin, andAspirin Products, Anti-Inflammatory drugs such as Advil, Aleve, Nuprin, Alka Seltzer, Pepto-Bismol and Various Herbs. Also stop taking diet medications. You may take multivitamins.

Aspirin Medication To Avoid

4-Way Cold Tabs5 action

5-Aminosalicyclic AcidAcetilsalicylic AcidAdprin-B products

Alka-Seltzer productsAmigesic

Anacin productsAnexsia w/ Codine

Argesic-SAArthra-G

Arthriten productsArthritis Foundation

Arthritis Pain FormulaArthritis Strength BC

ArthropanASA

AsacolAscriptin products

AspergumAsprimox products

AxotalAzdone

Azulfidine productsB-A-C

Backache MaximumBayer products

BC PowderBismatrol products

Buffered AspirinBufferin products

Buffetts 11Buffex

Butal/ASA/CaffButalbital Compound

Cama Arthritis PainCarisoprodol Compound

CheracolCholine MagnesiumCholine Salicylate

ColdCope

CoricidinCortisone Medications

Damason-PDarvon Compound-65

Darvon/ASADipentumDisalcid

Doan’s productsDolobidDristan

DuragesicEasprin

Ecotrin productsEmpirin products

EquagesicExcedrin products

Fiorgen PFFiorimal products

GelpirinGenprinGensan

Goody’s Extra StrengthHalfprin products

Headache PowdersIsollyl Improved

KaodeneLanorinal

Lortab ASAMagan

Magnaprin productsMagnesium Salicylate

MagsalMarnal

MarthriticMeprobamate

MesalamineMethocarbamol

Micrainin

MobidinMobigesic

MomentumMono-Gesic

Night-Time EffervescentNorgesic productsNorwich products

OlsalazineOrphengesic products

OxycodonePabalate products

P-A-CPain Reliever Tabs

PanasalPentasa

Pepto-BismolPercodan products

Phenaphen/Codeine #3Pink Bismuth

PowderProductsProducts

Propoxyphene CompoundReliever

RobaxisalRowasaRoxeprin

Saletoproducts

SalflexSalicylate products

SalsalateSalsitab

Scot-Tussin OriginalSine-offSinutab

Sodium SalicylateSodol CompoundSoma CompoundSt. Joseph Aspirin

Strength ReliefSulfasalazine

SupacSuprax

Synalgos-DCTalwin

TriaminicinTricosalTrilisate

TrisalicylateTussanil DH

Tussirex productsUrsinus-Inlay

VanquishWesprin

Willow Bark productsZorprin

Ibuprofen Medications To Avoid

ActronAcular (opthalmic)

Advil productsAleve

Anaprox productsAnsaid

CataflamClinorilDaypro

DicofenacDimetapp Sinus

Dristan SinusEtodolacFeldene

FenoprofenFlurbiprofen

GenprilHaltran

IBUIbuprin

IbuprofenIbuprohm

Indochron E-RIndocin products

Indomethacin productsKetoprofenKetorolac

LodineMeclofenmate

MeclomenMefanamic Acid

MenadolMidol productsMotrin productsNabumetone

Nalfon productsNaprelan

Naprosyn productsNaprox XNaproxen

NuprinOcufen (ophthalmic)

Orudis productsOruvail

OxaprozinPiroxicam

PonstelProfenalRelafen

RhinocapsSine-Aid products

SulindacSuprofen

Tolectin productsTolmetinToradol

Voltaren

Other Medications To Avoid

400mgs per day)4-Way w/Codeine

A.C.A.A-A Compound

AccutrimActifedAderalAnexsia

AnisindioneAnturane

Arthritis BufferinBC Tablets

Childrens AdvilClinoril CContac

CoumadinDalteparin injection

DicumerolDipyridamoleDoxycycline

EmagrinEnoxaprin injection

FlagylFragmin Injection

FuradantinGarlic

HeparinHydrocortisone

IsollylLovenox injection

MacrodantinMAO Inhibitors: Nardil;

MarhanMellaril

MiradonNardil

OpasalPan-PACParnate

Parnate; MaplinPentoxyfylline

PersantinePheylpropanolamine

PrednisoneProtaminePyrroxate

Ru-TussSalatinSinex

SofarinSolticeSparine

StelazineSulfinpyrazone

TenuateTenuate Dospan

ThorazineTiclid

TiclopidineTrentalUrsinus

Vitamin E (no more thanWarfarin

Tryciclic Antidepressants Medication To Avoid

AdapinAmitriptylineAmoxapine

AnafranilAsendinAventyl

ClomipramineDesipramine

DoxepinElavil

EndepEtrafon products

ImipramineJaimine

Limbitrol productsLudiomil

Maprotiline

NorpraminNortriptyline

PamelorPertofraneProtriptylineSinequanSurmontilTofranilTriavil

TrimipramineVicactil

Herbal Medications To Avoid

Black CohoshEchinacea

EphedraGinkgo Biloba

GinsengGlycosides

Herbal DiureticsKava

MeletoninSt. John’s Wort

Yohimbe

Directions to 4725 SW 148th Ave #202, Davie, FL 3333120.2 mi – about 27 mins

Fort Lauderdale-Hollywood International Airport, 100 Aviation Boulevar... https://maps.google.com/maps?f=d&source=s_d&saddr=Fort+Lauderda...

1 of 2 8/29/2012 9:03 AM

These directions are for planning purposes only. You may find that construction projects, traffic, weather, or other events may cause conditions todiffer from the map results, and you should plan your route accordingly. You must obey all signs or notices regarding your route.

Map data ©2012 Google

Directions weren't right? Please find your route on maps.google.com and click "Report a problem" at the bottom left.

Fort Lauderdale-Hollywood International Airport, 100 Aviation Boulevard, FortLauderdale, FL 33315

1. Head east on Old Dixie Hwy toward Fuel Tender RdAbout 2 mins

go 0.6 mitotal 0.6 mi

2. Turn left onto Fuel Tender RdAbout 50 secs


3. Continue onto SW 2nd Ave go 0.2 mitotal 1.0 mi

4. Turn left to stay on SW 2nd AveAbout 2 mins


5. Turn left onto FL-84 WAbout 2 mins


6. Slight right to stay on FL-84 WAbout 3 mins


7. Keep left at the fork, follow signs for I-595 W/FL-84 W and merge onto I-595 WAbout 10 mins


8. Take the exit on the left onto I-75 S toward MiamiAbout 6 mins


9. Take exit 13A for Griffin Rd E go 0.3 mitotal 19.5 mi

10. Merge onto Griffin RdAbout 52 secs


11. Turn right onto SW 148th Ave/Volunteer RdDestination will be on the right


4725 SW 148th Ave #202, Davie, FL 33331

Fort Lauderdale-Hollywood International Airport, 100 Aviation Boulevar... https://maps.google.com/maps?f=d&source=s_d&saddr=Fort+Lauderda...

2 of 2 8/29/2012 9:03 AM

FTM Transgender Preop Packet rev21113-1.pdf

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Transcript of FTM Transgender Preop Packet rev21113-1.pdf