AESTHETIC PLASTIC SURGERY INSTITUTE, P.A. Dr. Charles E.

Garramone Board Certified Plastic & Reconstructive Surgery

P L A S T I C

4725 SW 148th Ave, #202, Davie, FL 33330 Phone: (954) 752-7842 Fax: (954) 473-2454 E-mail: drgarramone@drgarramone.com Web: www.transgenderflorida.com

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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 (photos@drgarramone.com) 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 peoples privacy and do not photograph anyone else in our office.

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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 clients psychosocial assessment, including any diagnoses (please attach separate letter describing the status) The duration of the mental health professionals 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 patients request for sur gery (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:______________________________________________________

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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. Garramones 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. Garramones 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. Garramones 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 practices 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) __________________________________________ Please print the name of the patient

______________ Date

Medications to Avoid Before and After Surgery

If you are taking any medications on this list, they should be discontinued 14-21 days prior to surgery and only TYLENOL should be taken for the pain. All other medications that you are currently taking must be specifically cleared by Dr. Garramone prior to surgery. It is absolutely necessary that all of your current medications be specifically cleared by Dr. Garramone and nursing staff. Common medications that are taken are Aspirin, and Aspirin Products, Anti-Inflammatory drugs such as Advil, Aleve, Nuprin, Alka Seltzer, PeptoBismol and Various Herbs. Also stop taking diet medications. You may take multivitamins. Aspirin Medication To Avoid 4-Way Cold Tabs 5 action 5-Aminosalicyclic Acid Acetilsalicylic Acid Adprin-B products Alka-Seltzer products Amigesic Anacin products Anexsia w/ Codine Argesic-SA Arthra-G Arthriten products Arthritis Foundation Arthritis Pain Formula Arthritis Strength BC Arthropan ASA Asacol Ascriptin products Aspergum Asprimox products Axotal Azdone Azulfidine products B-A-C Backache Maximum Bayer products BC Powder Bismatrol products Buffered Aspirin Bufferin products Buffetts 11 Buffex Butal/ASA/Caff Butalbital Compound Cama Arthritis Pain Carisoprodol Compound Cheracol Choline Magnesium Choline Salicylate Cold Cope Coricidin Cortisone Medications Damason-P Darvon Compound-65 Darvon/ASA Dipentum Disalcid Doans products Dolobid Dristan Duragesic Easprin Ecotrin products Empirin products Equagesic Excedrin products Fiorgen PF Fiorimal products Gelpirin Genprin Gensan Goodys Extra Strength Halfprin products Headache Powders Isollyl Improved Kaodene Lanorinal Lortab ASA Magan Magnaprin products Magnesium Salicylate Magsal Marnal Marthritic Meprobamate Mesalamine Methocarbamol Micrainin

Mobidin Mobigesic Momentum Mono-Gesic Night-Time Effervescent Norgesic products Norwich products Olsalazine Orphengesic products Oxycodone Pabalate products P-A-C Pain Reliever Tabs Panasal Pentasa Pepto-Bismol Percodan products Phenaphen/Codeine #3 Pink Bismuth Powder Products Products Propoxyphene Compound Reliever Robaxisal Rowasa Roxeprin Saletoproducts

Salflex Salicylate products Salsalate Salsitab Scot-Tussin Original Sine-off Sinutab Sodium Salicylate Sodol Compound Soma Compound St. Joseph Aspirin Strength Relief Sulfasalazine Supac Suprax Synalgos-DC Talwin Triaminicin Tricosal Trilisate Trisalicylate Tussanil DH Tussirex products Ursinus-Inlay Vanquish Wesprin Willow Bark products Zorprin

Ibuprofen Medications To Avoid Actron Acular (opthalmic) Advil products Aleve Anaprox products Ansaid Cataflam Clinoril Daypro Dicofenac Dimetapp Sinus Dristan Sinus Etodolac Feldene Fenoprofen Flurbiprofen Genpril Haltran IBU Ibuprin Ibuprofen Ibuprohm Indochron E-R Indocin products Indomethacin products Ketoprofen Ketorolac Lodine Meclofenmate Meclomen Mefanamic Acid Menadol Midol products Motrin products Nabumetone Nalfon products Naprelan Naprosyn products Naprox X Naproxen

Nuprin Ocufen (ophthalmic) Orudis products Oruvail Oxaprozin Piroxicam Ponstel Profenal Relafen Other Medications To Avoid 400mgs per day) 4-Way w/Codeine A.C.A. A-A Compound Accutrim Actifed Aderal Anexsia Anisindione Anturane Arthritis Bufferin BC Tablets Childrens Advil Clinoril C Contac Coumadin Dalteparin injection Dicumerol Dipyridamole Doxycycline Emagrin Enoxaprin injection Flagyl Fragmin Injection Furadantin Garlic Heparin Hydrocortisone Isollyl Lovenox injection Macrodantin MAO Inhibitors: Nardil;

Rhinocaps Sine-Aid products Sulindac Suprofen Tolectin products Tolmetin Toradol Voltaren

Marhan Mellaril Miradon Nardil Opasal Pan-PAC Parnate Parnate; Maplin Pentoxyfylline Persantine Pheylpropanolamine Prednisone Protamine Pyrroxate Ru-Tuss Salatin Sinex Sofarin Soltice Sparine Stelazine Sulfinpyrazone Tenuate Tenuate Dospan Thorazine Ticlid Ticlopidine Trental Ursinus Vitamin E (no more than Warfarin

Tryciclic Antidepressants Medication To Avoid Adapin Amitriptyline Amoxapine Anafranil Asendin Aventyl

Clomipramine Desipramine Doxepin Elavil Endep Etrafon products Imipramine Jaimine Limbitrol products Ludiomil Maprotiline Herbal Medications To Avoid

Norpramin Nortriptyline Pamelor Pertofrane Protriptyline Sinequan Surmontil Tofranil Triavil Trimipramine Vicactil

Black Cohosh Echinacea Ephedra Ginkgo Biloba Ginseng Glycosides

Herbal Diuretics Kava Meletonin St. Johns Wort Yohimbe

Fort Lauderdale-Hollywood International Airport, 100 Aviation Boulevar...

https://maps.google.com/maps?f=d&source=s_d&saddr=Fort+Lauderda...

Directions to 4725 SW 148th Ave #202, Davie, FL 33331 20.2 mi about 27 mins

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Fort Lauderdale-Hollywood International Airport, 100 Aviation Boulevar...

https://maps.google.com/maps?f=d&source=s_d&saddr=Fort+Lauderda...

Fort Lauderdale-Hollywood International Airport, 100 Aviation Boulevard, Fort Lauderdale, FL 33315
1. Head east on Old Dixie Hwy toward Fuel Tender Rd About 2 mins 2. Turn left onto Fuel Tender Rd About 50 secs 3. Continue onto SW 2nd Ave 4. Turn left to stay on SW 2nd Ave About 2 mins 5. Turn left onto FL-84 W About 2 mins 6. Slight right to stay on FL-84 W About 3 mins 7. Keep left at the fork, follow signs for I-595 W/FL-84 W and merge onto I-595 W About 10 mins 8. Take the exit on the left onto I-75 S toward Miami About 6 mins 9. Take exit 13A for Griffin Rd E 10. Merge onto Griffin Rd About 52 secs 11. Turn right onto SW 148th Ave/Volunteer Rd Destination will be on the right go 0.6 mi total 0.6 mi go 0.3 mi total 0.9 mi go 0.2 mi total 1.0 mi go 0.7 mi total 1.7 mi go 1.4 mi total 3.1 mi go 1.8 mi total 4.9 mi go 9.3 mi total 14.2 mi go 5.0 mi total 19.2 mi go 0.3 mi total 19.5 mi go 0.6 mi total 20.1 mi go 0.1 mi total 20.2 mi

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

These directions are for planning purposes only. You may find that construction projects, traffic, weather, or other events may cause conditions to differ 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.

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