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Patient Registration Form

Medical History Form

Personal Medical History

Please mark YES for all past and present medical conditions.

Hair Evaluation Form

Past Hair Surgery History

Surgery 1

Surgery 2

Surgery 3

Disclosure and Patient Consent Agreement for Minor Outpatient Surgery

1. I hereby grant permission for Michael W.Vories, M.D. to perform suitable operations and surgical procedures and to administer local anesthesia, muscle relaxants, minor sedatives, antibiotics, and other medications as they deem necessary for treatment of my hair loss. I have the right as a patient to be informed about my condition and the recommended surgical, medical, or diagnostic procedure to be used so that I may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not intended to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

I have read and understand the following general definitions of hair restoration procedures:

HAIR TRANSPLANTATION, related medical terms:

Donor Area: Follicular units are harvested from the donor area located on the back of the scalp between the ears and sides of the head.

Hair Density: Individuals vary considerably in the density of the hair in the donor area. Hair density is determined by the closeness of follicles to one another, not by the texture or caliber of the hair.

Graft Size: Follicles are individually extracted. Graft totals differ from Hair Follicle totals, 1 Graft = 1- 4 Individual Hairs.

2. I understand that the treatment of my hair loss may require 1-3 sessions in each area of hair loss. I further understand that the doctors may vary the interval between these procedures to achieve the optimum results and to fit in with my schedule and appearance requirements.

3. I understand the following surgical procedure is planned and I voluntarily consent and authorize the Follicular Unit Extraction (F.U.E.) method. The doctor may discover conditions that require additional or different procedures than those planned. I authorize the doctor to perform such other procedures that are advisable in his professional judgment. The procedure should in most cases provide definite hair growth, but the density will not approximate that on the lower part of the back of the head or sides of the head even after several procedures. Hair graft success is approximately 90% normally, but individual variations can be expected. The results are as permanent as the hair growth at the donor site. I fully understand that no warranty or guarantee has been made to me as to result or cure. Your head will be trimmed for the F.U.E. procedure in order for the doctor to access all follicles needed for extraction.

4. I understand that the doctor employs surgical technicians who perform some of the technical aspects of the procedures under direct supervision. The surgical technicians will provide placement of the grafts to be subsequently adjusted by the doctor. I understand that all surgical cutting, design, and layout of grafts are done exclusively by the doctor.

5. I realize that common to any procedure is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions, and even death. I also realize that the following risks and hazards may occur in connection with this particular procedure:

  • a) Unsatisfactory appearance and / or low density of the transplanted hair.
  • b) Possible numbness in the back of the head, which usually subsides within a few weeks to a few months, but on rare occasions, could be permanent.
  • c) Creation of additional problems such as poor healing, skin loss, nerve damage, or painful or unattractive scarring.
  • d) Blood collection under the skin requiring removal.
  • e) Problems relating to anesthesia.

6. I understand that anesthesia involves additional risks and hazards, but can request the use of local anesthetics, oral pain medication, and oral sedative medication for the relief and protection from pain during the planned and any additional procedures. I realize the anesthesia may have to be changed, possibly without explanation. I understand that certain consequences may result from the use of any local anesthetic, including respiratory problems, drug reactions, paralysis, brain damage, or even death.

7. The procedure has been explained to me by the doctor, and I completely understand the nature and consequences of the procedure. The following points were specifically made clear:

  • a) The same complications may follow this cosmetic surgical procedure as may follow any other type of surgical procedure. These include the following complication which rarely occur: inflammation, infection, excessive scar issue, permanent loss of feeling in the scalp of the crown head, allergy to suture material, foreign body reaction, blood vessel reaction, dermoid cyst formation, allergy to medications, and change of skin color around grafts.
  • b) Following the procedure, I may expect some degree of swelling and possibly some discoloration or bruising temporarily. I understand that I must sleep with my head elevated at 30 to 45 degrees for 3 nights and use forehead icepacks, to help prevent swelling.

8. I understand that Male or Female Pattern Baldness is a progressive disorder which may start at an early age and progress throughout life. Therefore, I understand that the doctor has made his best estimate of my future pattern based on family history and other factors, but it is impossible to determine exactly how far it will progress. I further understand that it is important not to start these procedures at too young an age, or if starting young, to be very conservative in the hair restoration progress. I understand that, if I am losing hair slowly, it is best to replace my hair slowly (over a few years to match the rate of natural hair loss). I agree to work with the doctor in locating the hairline or other factors according to his advice so it will not be too low or in an inappropriate place. I understand that the interval between hair transplant procedures is usually 10-12 months. This is to allow time for the skin to remodel and smooth itself, and for hair to grow out. Healing rates vary, so my interval could be more or less. Usually, 1-3 transplant sessions are needed in any one area, depending on density I desire. For example, 1-3 sessions are needed for the hairline, midscalp, and the crown. However, hairline, midscalp, and crown may be transplanted simultaneously. I further understand that, as hair loss progresses, future touch-up sessions maybe needed to fill new areas of hair loss surrounding the previously transplanted area. I acknowledge that hair restoration is an art form, and thus cannot be properly judged until it is completed. Therefore, I agree that I will not achieve final results until I have completed my entire treatment plan, including any additional procedures I may require for touch-up or additional hair loss on my part, and the hair has all grown for 1-2 years. I understand that the treatment plan is 1-3 sessions in each area depending on the density desired, plus touch-ups at 1 and 2 years, plus an additional 1-3 session in any area of additional hair loss, as my donor supply allows.

9. I have read my post-operative instructions and I will follow them precisely.

10. I understand that numbness may occur temporarily on the scalp and is the result of trauma to superficial nerves which run throughout the scalp. I understand that there may be some tingling or other bizarre feelings from time to time as these nerves are healing and growing back. I further understand that it will take 6-18 months for the complete regrowth of these nerves and proper healing, and that rarely there may be a residual small area of no feeling on the crown or vertex of the scalp.

11. Permission is hereby granted for the taking of pre-operative and post-operative photographs of my procedures for use in medical research, the medical records of my case, and advertising to the general public as long as my identity and face are concealed, so that no one would know who I am. I give my permission for use of my photographs, comments, and video images for medical publications, lectures, advertising and marketing purposes regarding Carolina Hair Surgery. All multi- media information is the sole property of Carolina Hair Surgery. I understand that all information regarding myself and my procedures is always kept privileged and confidential. Carolina Hair Surgery retains all “Intellectual Property Rights” in and to its Website content, the Procedure and Services. Visitors are granted only a limited, non-exclusive, non-transferable license to access and view the Website and Patients are granted only a limited, non-exclusive, non-transferable license to access and use the Website, Procedure and Services. As used herein “Intellectual Property Rights” includes patents, copyrights and trademarks and other legal protections afforded by the United States and other countries. Neither Visitors nor Patients shall copy, reprint, re-broadcast or disseminate any such material without the prior written consent of Carolina Hair Surgery.

12. I have no history of keloid formation.

13. I understand that my grafts will take from a few weeks to a few months to begin growing, and I agree to be patient in waiting during that time.

14. I understand sometimes placing grafts in a given area with some remaining hair in it may cause hair shock, which generally results in the hair in the given area to fall out before regrowing in three to four months, although it may never regrow in rare cases. I also understand that if I have used Rogaine for an extended period, I may be at a greater risk for hair shock and failure to regrow hair, if I discontinue Rogaine.

15. I understand that I may have an ingrown hair or two a few months after my procedures, and I agree that I will immediately come to the office to have the ingrown hairs removed so as not to damage my surrounding grafts.

16. I understand that if I bump my head or otherwise injure the fresh grafts, some of them may come out even though they are held in by the adhesive or crusts. I further understand that if this should happen, I will follow my post-operative instructions regarding this exactly.

17. I understand that I may experience the eruption of pimples in the transplanted area. While this is usually a temporary harmless phase that occurs in the second through sixth month post transplant, I will contact the clinic for evaluation if this occurs.

18. I further understand that if I am a slow healer or I am losing hair slowly, it may be necessary to take 1- 5 years between transplant procedures.

19. I understand that sometimes a patient may have poor healing, which may cause a ridge where the grafts are placed (as a result of fibrosis during healing). This could require graft removal or other treatment in order to remove the ridging. This ridging condition is very rare with follicular unit grafts.

20. I understand that there may be some post operative oozing or light bleeding at the donor site, or in the case of transplants, from or around a graft in the case of transplants. I agree to follow my post-operative instructions and place immediate pressure on such a spot and to subsequently call the doctor.

21. I know that the practice of medicine and surgery is not an exact science, and therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no absolute guarantee has been made by anyone regarding the operation which I have herein requested and authorized, but that the doctor will make his best effort on my behalf.

22. I agree to carry out the following list of patient responsibilities:

  • a) Provide accurate and complete information about present symptoms, past illnesses, and other health matters to the best of my knowledge.
  • b) Let the doctor know whether or not I clearly understand what the treatment will be and what is expected of me.
  • c) Follow the doctor’s treatment recommendations, and the Post-Operation Instructions.
  • d) Keep appointments and notify medical office if I am unable to keep an appointment.
  • e) Make prompt payment according to the Fee Schedule.
  • f) Follow medical group’s rules and regulations.
  • g) Please limit cell phone use during the procedure to essential family communications only.
  • h) Be considerate of the rights of other patients and medical staff.
  • i) Respect the property of others.

It is only when patients assume these responsibilities that they are acting as active members of their health care team.

23. I acknowledge that if I have had hair restoration procedures done by another physician, or have had old plug-type grafts done in years past, or require that my donor hair is taken through old scarred donor areas, or I have a limited availability of donor hair, such as in Norwood Class 7 hair loss, I can expect somewhat limited results. For example, my density will not be as good as if I had an ample supply of donor hair. Donor scars through old scarred up donor areas will be wider than normal, and several of my grafts that are transplanted into old scarred up receptor areas may not grow.

24. I certify that I have read and fully understand the above consent to operate, and that the explanations therein referred to were made. I have been given the opportunity to ask questions about my condition, alternative forms of anesthesia and treatment, risks of no treatment, the procedure to be used, the risks and hazards involved, and I believe that I have sufficient information to give an informed consent at this time.

25. I have reviewed the following prior to this procedure, and understand and will follow them exactly: Pre-Operative Checklist, Consultation Record, general information for Hair Restoration Patients and Post-Operative Instructions for Hair Transplantation. All information contained in the Website, Brochures and Pamphlets is provided as is without any warranties of any kind whatsoever. CAROLINA HAIR SURGERY DISCLAIMS ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES REGARDING OUTCOME OR DENSITY. Carolina Hair Surgery reserves the right, without prior notice, to: (i) modify this Agreement; or (ii) modify or withdraw the Website, Service or Reports at any time; or (iii) remove any information or material from the Website, Service or Reports that it determines to be objectionable; or (iv) terminate or limit the participation of any Patient, with or without cause.

26. I understand that the number of transplant grafts given to me were the doctor’s best estimates. I also understand that I may require additional procedures due to subsequent hair loss, which cannot be predicted, or other factors. I agree to pay the fees for the number of transplant grafts that I elect to have. Post-surgical follow up visits that are limited to the surgery are performed as part of the surgical fee. I agree to pay a Non-Refundable scheduling fee of ten percent (10%) which will be applied to the procedure fee. All remaining fees will have to be paid the day of surgery in order to perform surgery. It is at the discretion of Carolina Hair Surgery whether a refund is appropriate for a specific patient circumstance. Carolina Hair Surgery has a NO REFUND POLICY on hair restoration services provided by our clinic. All charges are nondeniable.

27. Carolina Hair Surgery does not discriminate in providing treatment or services on the basis of race, color, sex, religious creed, ancestry, national origin, martial status, age, disability (including HIV), or sexual orientation.

28. This Agreement shall be governed by the laws of the State of South Carolina, in which the medical office is located, and will apply except as to conflicts of laws. The prevailing party in any court, administrative, or other proceedings to resolve any disputes between us will be entitled to reimbursement of (1) all of its attorneys’ fees and related costs of the proceeding, and (2) reasonable collection fees. YOU ACKNOWLEDGE THAT WE ARE NOT LIABLE FOR ANY NEGLIGENT ACTS OCCURRING IN THE PERFORMANCE OF DUTIES PURSUANT TO THIS CONSENT AGREEMENT. Should I ever have a reason to believe that Dr. Vories is guilty of medical malpractice, I hereby agree to consult with at least one other expert in the profession of hair restoration surgery before consulting with a lawyer. In the event of any dispute you bring under this consent Agreement, our refunding the total amount of the procedure fee will fulfill any obligation we have to you in law and equity. Our refunding of this amount to you will then cancel this consent Agreement. All claims against Carolina Hair Surgery shall be asserted within one year of arising or be forever barred. In no event shall Carolina Hair Surgery or its parents, subsidiaries, divisions, successors, affiliates, principals, agents, employees or other party involved in creating, producing, or delivering the procedure be liable to you for any indirect, consequential, exemplary, incidental, special or punitive damages, including lost profits, even if Carolina Hair Surgery has been advised of the possibility of such damages. Regardless of the form of any action, Carolina Hair Surgery liability shall not exceed the amount paid to Carolina Hair Surgery by you. If we cancel this consent agreement for any reason, neither party will then have any further obligation under this Agreement to the other. This is the entire agreement of both parties and may be modified only by a writing signed by Carolina Hair Surgery.

29. I also understand that I must not operate any motorized vehicle for 24 hours following surgery. I hereby release Dr. Michael W. Vories from any and all actions, loss or injury sustained by me as a consequence of operating any motorized vehicle.

30. Previous hair restoration procedures by other procedures by other physicians have resulted in problems that may impede your final results.

 

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Legal Disclaimer

Our Goal:
To provide our patients quality hair restoration surgery and medical treatment for hair loss.

Medical Disclaimer:
Any medical, health advice, or information provided on our web-site, on-line consults, brochures, or any other medical literature is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her existing physician. Please note: Carolina Hair Surgery does not assume any liability or make any guarantee for the information and data contained in our web site or for any diagnosis or treatment made in reliance thereon.

Privacy Policy:
We respect the confidentiality of any information, including your identity. We honor or exceed legal requirements of medical/health information privacy in the United States. We do not distribute, sell, or rent any of your personally identifiable information to any third parties. Nor is any of your information, such as a Social Security number, shared with anyone unless you sign a consent form to allow the use of your personal information.

Fees Agreement, Payment, and Service Terminology

Surgical Services
Initial consultations, post operative visits which include the post-operative follow up, suture removal, and six month evaluation are included in the surgery fee. If you are also a medically managed patient all office visits charges start after the first 6 months. A Non-Refundable scheduling fee of 10% of the final surgery fee is required to secure a surgery date. All remaining fees are due on the day of surgery in order to perform the surgery: If a patient cancels a scheduled surgery after having paid in full, Carolina Hair Surgery retains sole discretion over whether to refund the fee minus the deposit based on the circumstances of the patient.

All surgery dates are based on a first deposit received. first surgery performed.
All surgery dates must be approved by Michael Vories, MD.
All pre-operative labs and tests requested by the physician are performed at the expense of the patient.
All pre-operative prescription medications are filled at the expense of the patient. Intra-operative medications given are included in the surgical fee.

Medical Services Initial consultations for medical management (Finasteride) of hair loss are also performed at no charge. Subsequent follow-up evaluations are performed at a cost of$120.00 per visit. All follow up visits are scheduled at the discretion of the physician.

Carolina Hair Surgery accepts only the following payment methods:
Cash, Personal Check, Bank Cashiers Check, Visa, Master Card, Discover, American Express, and Financial Agreements from Care Credit. We gladly accept your checks. When you provide a check as payment, you authorize us to use information from the check to make a one-time electronic transfer from your account, or to process the payment as a check transaction. You authorize us to collect a fee of $30.00 (plus a bank fee if allowed by state law) through electronic transfer from your account if your payment is returned unpaid. Please include the following on your check: Driver's License ik Full Name, Street Address, Phone Numbers. Third Party and Business checks are not accepted. There is no insurance coverage for the procedure, office visits, or medication prescribed from Carolina Hair Surgery.

There is a No Refund Policy on hair restoration services provided by Carolina Hair Surgery.

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