Online Medical History Dr Montanari’s Private Practice

Dear Patient,

Welcome to the private practice for plastic and cosmetic surgery run byDr Michaela Montanari. To ensure we can provide you with the best possible care, we would ask you to carefully complete the following questions and details before your first appointment.

* = Mandatory information

First name

Name

Street, no.

Postcode, city

Date of birth

Telephone

Mobile number.

Contact number for next of kin (emergency contact)

Occupation

General practitioner

Referring doctor

Invoicing via

Self-payer Private insurance Follow-up cost insurance

Name of the insurance company

Intimate correction

Other reason for the visit

Explanation

I would like to be examined, advised and treated by Dr Michaela Montanari and/or Dr Anna Maria Bugariu.

I am aware of this and agree that, as a privately insured patient or a self-paying patient, I will enter into a direct contract with the treating doctor(s).

There is therefore no contractual relationship between the doctor and the private health insurance provider or (and) the health allowance scheme. The appropriateness of the fee is determined on a case-by-case basis, depending on the severity of the condition and the medical or aesthetic consultation and treatment required.

Depending on the amount of work involved, higher mark-up rates than 2.3 times or 3.5 times the fees set out in the Medical Fees Schedule may therefore be applied when issuing invoices. Under Section 12(1) of the GOÄ, the invoice amount becomes due in full upon receipt of the statement of account – irrespective of the amount reimbursed by the private insurance company or (and) the subsidy authority.

Please note that we cannot guarantee that the benefits office and/or your private health insurance will cover the full cost of treatment. We would be happy to provide you with a cost estimate, which can be used as a claim form, before any major treatment begins.

Settlement of the fee claim by way of assignment of the claim for reimbursement against the patient’s private health insurance provider or the relevant government health allowance agency is excluded. The patient is aware that the health insurance provider or government health allowance agency may refuse to reimburse the invoice amount in full or in part.

I am aware that, for example, in the event of illness, I must cancel agreed treatment or surgery appointments at least 3 working days in advance; otherwise, I will be charged for the scheduled service or the unused time (Sections 304 and 615 of the German Civil Code (BGB)). Examination, consultation and treatment will commence once this agreement has been signed.

If ‘Other’ or a recommendation by

If ‘Other’, please explain

Other medical conditions:

Addition / Note: Allergies

Addendum: Cosmetic treatments:

Have any other (medical) operations been carried out?

Have you ever had a local anaesthetic during an operation or at the dentist?

Did you experience any complications following surgery?

no increased tendency to bleed/post-operative bleeding Thrombosis Others

Supplement: Complications

Which medicines do you take regularly, and in what dosage?

Addition / Note: Medicines

Are you a smoker?

If so:

Do you drink alcohol regularly?

Do you bruise easily?

Your height

Your weight

Consent to processing

I have the Privacy policy I have read and agree to the following:

CONSENT to the processing of personal data, Fee Agreement and Questionnaire At Dr Michaela Montanari’s private practice, the collection and processing of personal data is essential for the provision of proper medical care; in accordance with the General Data Protection Regulation, your consent is required for this from 25 May 2018 onwards.

In all cases, the type of data processed, the scope of processing and any recipients are limited to what is necessary for the respective purpose. The data will be deleted once the purpose has been fulfilled, provided there is no statutory obligation to retain it or unless another need for storage arises from the processing itself.

Our „Patient Information on Data Protection“ has informed you that we may only pass on your data to third parties where this is required by law or where we have obtained your consent. In order to be able to pass on your data in connection with your treatment to other service providers (e.g. other doctors, hospitals, laboratories) (e.g. by means of a doctor’s letter), we require your consent. Without this, we are unable to provide adequate information to the doctors and service providers involved in your follow-up care. You may then need to provide the necessary information yourself.

We would ask you to confirm, by signing below, that you consent to your data being processed as described. You may withdraw your consent at any time by sending us an informal notification.

Consent to the transfer of data

I agree to the following:

CONSENT TO THE TRANSFER OF DATA AND DATA PROCESSING

I hereby consent to my medical treatment data being passed on to Dr Michaela Montanari’s private practice:

1. as part of the online appointment booking process with WM Onlinemarketing and Walther Maar Digital Marketing Agency

2. Appointment confirmation – we set aside specific time, staff and equipment for your scheduled consultation and/or treatment. For this reason, we will confirm your upcoming appointment by text message, email or telephone a few days in advance. As part of our recall programme, we may remind you of any necessary treatment steps and follow-up appointments by text message, email or post.

3. various billing bodies (private medical billing centres, associations of panel doctors, statutory health insurance funds, private insurers, accident insurance funds, subsidy agencies, follow-up cost insurers) solely for the purposes of submitting claims and/or billing. In individual cases, it may be necessary to transfer data to other authorised recipients

4. Furthermore, I agree that Dr Michaela Montanari’s private practice may use the services of Jasper + Driwa GmbH, Im Pinntal 60, 46244 Bottrop, and CGM Deutschland AG, as well as CGM one DokuAssistenten – GB Telemed, Maria Trost 21, 56070 Koblenz, and Takuta GmbH, Rellinghauser Strasse 111, 45128 Essen – for the purposes of booking appointments and sending reminders.

5. in the event that anaesthesia is required, to the relevant anaesthesia team

6. External investigations are necessary in specific treatment cases to supplement the findings or to plan further treatment through additional investigations carried out by third parties. These include, for example, laboratory and pathological examinations carried out by, amongst others, the Springorum and IML Gatermann laboratory consortia, and the Pathological Institute of Ruhr University Bochum at BG-Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789 Bochum. In the case of ultrasound examinations, the image files are stored on Cloud.clarius.com. In individual cases, it may be necessary to transfer data to other authorised recipients.

7. to the doctor providing further treatment (if necessary)

8. the Breast Implant Register and service providers for registration with the Breast Implant Register

9. Implant manufacturers (e.g. Polytech Health & Ästhetic GmbH, Altheimer Str. 32, 64807 Dieburg) for specific warranty services

I am aware that I may revoke this consent at any time, informally, with effect for the future; any data transfers carried out to date and covered by this consent remain lawful.

At the same time, I release the aforementioned doctors, or the doctors employed at the aforementioned institutions, as well as the staff involved in the respective processing, from their duty of confidentiality to the same extent.

By signing this, I confirm that I have been adequately informed about the intended processing of my personal data and that I voluntarily give my consent to such processing.

All this data is processed confidentially by Dr Michaela Montanari’s private practice, as all staff are bound by professional confidentiality in accordance with Section 203 of the German Criminal Code (StGB) and data protection regulations. Fast electronic communication via WhatsApp, Facebook Messenger, text messages and email is already an integral part of many people’s private lives. Patients, too, are increasingly valuing fast and, above all, electronic communication with their doctor – particularly following surgical procedures – as this allows for quick and straightforward communication.

If you wish, you can contact us via social media platforms such as SMS, WhatsApp and Facebook Messenger, or by email. From a technical point of view, this form of communication is not a secure, end-to-end-encrypted method of communication. The information is therefore less secure than it would be in a face-to-face conversation, an encrypted email or a sealed letter.

Dr Michaela Montanari expressly points out that the information may also be read, reused or otherwise utilised by third parties, and that, as a doctor, she accepts no responsibility or liability in this regard.

I hereby consent, of my own accord, to communicating via social media and/or by email.

Medical history

Online Medical History Dr Montanari’s Private Practice