NEW PATIENTS INTAKE FORMS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information. Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers' Compensation, Inmates, Required Uses and Disclosures. Under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.

You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights: Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under the federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your case or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request and receive confidential communications from us by alternate means or at an alternate location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and became effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Consent to Treatment: I acknowledge the need for medical services and hereby consent to receive care at Pacific Cosmetic and Facelift Center from Dr. Faraz Valaie, as well as from his nurses, aestheticians, or assistants. I understand that the practice of medicine is not an exact science and that any treatment and/or prescribed medication may involve risks and side effects. I will be informed about the availability of alternative treatments or procedures, including their benefits and risks, as well as the option of no treatment at all, except in emergencies.

Use of Medical Information: In accordance with California and federal law, Pacific Cosmetic and Facelift Center and Dr. Faraz Valaie will share medical information as necessary for the continuation of care and with other institutions or individuals as permitted by law. For example, since the center does not have an in-house lab, it uses an outsourced medical laboratory, and my lab work and personal information will be shared to facilitate any tests I may require. The center places high importance on the privacy and confidentiality of personal health information, with policies ensuring access to such information is limited to authorized personnel who need it to provide medical care. No patient information will leave the office electronically, by fax, or on paper without specific authorization from the patient.

Patients' Responsibilities: Patients are responsible for providing a complete and accurate medical history and for following the treatment plans and advice provided by their healthcare provider. Compliance with prescribed treatments, appointment schedules, and office policies are crucial for the effectiveness of care and treatment.

Financial Agreement: I agree that I am responsible for all charges for services provided to me, my spouse, and my dependents, payable in full on the day services are rendered. I understand that Pacific Cosmetic and Facelift Center and Dr. Faraz Valaie do not file or bill any insurance.

Payment Policy: All payments must be made prior to any procedure.

Cancellations: A notice of at least 48 hours is required for all cancellations.

No-Refund Policy: All payments are final, and no refunds will be issued under any circumstances. This no-refund policy applies to any payments made, including deposits, regardless of the receipt of services or the desirability of the results.

Patient's Right to Privacy: We are committed to protecting your privacy. Detailed information on how we protect your data, how you can access your medical records, and our record retention policy is available upon request.

Updates to Policies: Our office policies are reviewed annually. Any changes or updates will be communicated to our patients through our official communication channels or during your next visit.

Patient's Right to Revoke Consent: Patients may revoke their consent at any time. To revoke consent, a written notice must be submitted to our office. Please be aware that revoking consent may affect our ability to provide medical care.

Emergencies: In the event of a medical emergency, dial 911. For urgent needs requiring Dr. Valaie's attention, please contact the office at (949) 225-0101 or his cell phone at (949) 345-1010.

Right to Amend Health Information: You may request an amendment to your health information if you believe it is incorrect or incomplete, as long as the information is maintained by our practice. Requests must be made in writing and submitted to Pacific Cosmetic and Facelift Center, 1601 Dove St. #125, Newport Beach, CA 92660, with a supporting reason for the amendment.

Right to Receive a Copy of This Notice: You are entitled to receive a copy of this Notice of Privacy Practices at any time. To obtain a copy, please contact our office at the address above.

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. Complaints must be submitted in writing and will not result in any form of penalization. To file a complaint with our practice, please contact the address provided above.

Authorization for Other Uses and Disclosures: Our practice will obtain your written authorization for any uses and disclosures of your health information that are not covered by this notice or permitted by applicable law.

Contact Information: If you have questions about this notice or our health information privacy policies, please contact Pacific Cosmetic and Facelift Center or Dr. Valaie at (949) 225-0101.

Open Payments Database: Information about payments made by drug and device companies to physicians and teaching hospitals can be searched at https://openpaymentsdata.cms.gov.

ARTICLE 1: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

ARTICLE 2: I understand and agree that this Arbitration Agreement binds me and anyone else who may have a claim arising out of a related to all treatment or services provided by the physician, including any spouse or heirs of the patient and any children, whether born or unborn at the time of the occurrence giving rise to any claim. This includes, but is not limited to, all claims for monetary damages exceeding the jurisdictional limit of the small claims court, including, without limitation, suits for loss of consortium, wrongful death, emotional distress or punitive damages. I further understand and agree that if I sign this Agreement on behalf of some other person for whom I have responsibility, then, in addition to myself, such person(s) will also be bound by this Agreement,along with anyone else who may have a claim arising out of the treatment or services rendered to that person. I also understand and agree that this Agreement relates to claims against the physician and any consenting substitute physician, as well as the physicians partners, associates, association, corporation or partnership, and the employees, agents, and estates of any of them. I also hereby consent to the intervention or joinder in the arbitration proceeding of all parties relevant to a full and complete settlement of any dispute arbitrated under this Agreement, as set forth in the Medical Arbitration Rules of the California Medical Association and the California Hospital Association.

ARTICLE 3: I agree that the arbitrators have the same immunity from civil liability as that of a judicial officer when acting in the capacity of arbitrator under this Agreement. This immunity shall supplement, not supplant, any other applicable statutory or common law.

ARTICLE 4: I UNDERSTAND THAT I DO NOT HAVE TO SIGN THIS AGREEMENT TO RECEIVE THE PHYSICIAN’S SERVICES, AND THAT IF I DO SIGN THIS AGREEMENT AND CHANGE MY MIND WITHIN 30 DAYS OF TODAY, THEN I MAY CANCEL THIS AGREEMENT BY GIVING WRITTEN NOTICE TO THE UNDERSIGNED PHYSICIAN WITHIN 30 DAYS OF THE DATE OF MY SIGNATURE BELOW STATING THAT I WANT TO WITHDRAW FROM THIS ARBITRATION AGREEMENT.

ARTICLE 5: On behalf of myself and all others bound by this Agreement as set forth in Article 2, agreement is hereby given to be bound by the Medical Arbitration Rules of the California Medical Association and the California Hospital Association, as they may be amended from time to time, which Rules are hereby incorporated into this Agreement. A copy of these rules is included in the pamphlet in which this Agreement is found. Additional copies of the Rules are available from the California Medical Association, 1201 J Street, Suite #200 Attention: Publication department, Sacramento, CA 95814 or at www.cmanet.org. I understand that disputes covered by this Agreement will be covered by California law applicable to actions against health care providers, including the Medical Injury Compensation Reform Act of 1975 (including any amendments thereto).

ARTICLE 6: OPTIONAL: RETROACTIVE EFFECT
(Does not apply to new patients)

ARTICLE 7: I have read and understood all of the information in this pamphlet, including the introduction to the Patient-Physician Arbitration Agreement, this Agreement, and the Rules. I understand that in the case of any pregnant woman, the term “patient” as used herein means both the mother and the mother’s expected child or children.

If any provision of this Arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTACT.

I understand that I will be injected with a neuromodulator (e.g., Botox, Dysport, Xeomin, Jeuveau, or other FDA-approved neuromodulators that may be available now or developed in the future) by Dr. Valaie. These injections may be administered in areas such as the glabella muscles, forehead, crow’s feet, bunny lines on the nose, perioral muscles around the mouth, or in the neck muscles.

FDA Approval: It has been explained to me that while some uses of these neuromodulators are FDA approved for specific cosmetic applications, Dr. Valaie may use them in other areas based on his professional judgment and extensive experience. The applications used by Dr. Valaie are informed by his expertise in facial anatomy and neuromodulator pharmacodynamics.

Treatment Goals and Frequency: The goal of this treatment is to decrease the appearance of wrinkles in the treated areas. This paralysis is temporary, requiring re-injection within three to four months. Alternative temporary and more permanent treatments have been discussed.

Possible Side Effects and Risks: I understand that possible side effects include, but are not limited to:

Swelling, rash, headache, local numbness.
Pain at the injection site, bruising, respiratory issues, flu-like symptoms, allergic reactions.
Temporary local weakness, unintended muscle weakness.
Eyebrow or eyelid drooping or unintended eyebrow elevation.
In rare cases, corneal exposure, impaired vision, or double vision.
Emergency Contact Information: In case of a severe reaction or emergency post-treatment, I will immediately contact emergency services by dialing 911. Following that, I will notify Dr. Valaie of the situation by contacting him directly at (949) 345-1010.

Follow-Up Treatments and Care Instructions: I understand that more than one injection may be necessary to achieve the desired results and agree to follow all aftercare instructions provided by Dr. Valaie for optimal healing. There may be cases of uneven appearance which can typically be corrected with further injections.

Consent to Treatment with Neuromodulators: I understand and agree that Dr. Valaie may use any current or future FDA-approved neuromodulators interchangeably, based on the treatment plan we have discussed. I acknowledge that all services rendered are charged directly to me, and I am personally responsible for payment. In the event of non-payment, I agree to bear the cost of collection, court costs, and reasonable legal fees if required.

This consent form is provided to inform you about the dermal filler procedure, its risks, benefits, and associated care. It is important to read and understand each point before signing this form. If you have any questions, please discuss them with Dr. Valaie or our staff before your treatment.

Procedure Description

Treatment Overview: I understand that I will be injected with a dermal filler in the facial area using a fine gauge needle intradermally or subdermally. This treatment is intended to improve the appearance of facial wrinkles.
FDA Approval and Off-Label Use: All dermal fillers used by Dr. Valaie are FDA approved, though they are approved for various uses. Dr. Valaie may use these fillers in areas and for purposes that are not necessarily FDA approved, based on his professional judgment to achieve desired cosmetic outcomes.
Risks and Possible Side Effects 3. Expected Outcomes and Multiple Treatments: Multiple treatments may be necessary to achieve the desired results, which typically last six months to two years. Touch-up treatments may be required, and no guarantees can be made regarding the final results.

Comprehensive Risk List:I am aware of the possible side effects, which include but are not limited to allergic reactions, infection, poor cosmetic outcomes, bleeding, tenderness, pain, redness, bruising, scarring, sensory issues, temporary or long-term muscle paralysis, dark spots, lumps and bumps, Keloid formation, swelling, acneiform eruptions, inflammatory nodules, vascular occlusion, and potential cancer risks. Vascular occlusion can lead to serious consequences such as blindness.
Patient Responsibilities 5. Medical History and Allergies: I will inform Dr. Valaie of any allergies, history of Keloid formation, use of blood thinners, or any medical conditions that may affect the treatment.

Pre and Post-Treatment Care: I acknowledge the importance of following pre and post-treatment instructions to support healing and minimize risks. I understand that specific instructions will be provided to me as part of the next steps in my treatment process.
Financial Agreement 7. Payment Responsibility: I understand that I am financially responsible for all treatments received. I acknowledge that there are no refunds for treatments once performed, regardless of my satisfaction level.

Privacy and Communication 8. Contact and Privacy: I agree to contact Dr. Valaie directly at (949) 225 0101 or his cell (949) 345 1010 in case of any concerns post-treatment. I understand that my personal information will be handled confidentially and used only as necessary for my treatment.

Consent Confirmation 9. Voluntary Consent: I confirm that I am at least 18 years old and have carefully read and fully understood this consent form along with any other related consent forms provided. I consent to proceed with the treatment understanding all the risks and benefits as explained. I acknowledge that I will have the opportunity to ask questions about the procedures before giving my consent.

By signing this form, I release Pacific Cosmetic and Facelift Center, its medical staff, and Dr. Valaie from any liability associated with these procedures. This agreement is binding upon my relatives, legal representatives, heirs, and assigns.

Dr. Valaie, always takes photos!

-------------------------------------------------------------

I consent for medical photographs to be made of me. I understand that the information may be used in my medical record, for purposes of assessment of my treatment’s results.

Please be aware that video and audio surveillance is active in our office waiting room, as well as in certain examination, consultation, and procedure rooms.

If you prefer not to be recorded, do not sign this document and inform us before scheduling your appointment. We will then make arrangements to deactivate our cameras for the duration of your visit.

By signing below, you consent to your video and/or audio being recorded by our surveillance systems.