UWi-Iealth

 

Non-Covered Self Pay Procedure Agreement

Wren Vetens

mm: --

Vou are scheduled for the following procedure on 12/27/2017 with Dr. Katherine Gast,
MD. This procedure will be performed at University Hospital in Madison, Wi.

The package price below includes the physician's fee, facility fee and anesthesra fees,
pathology on testes, post surgery labs to include CBC and Creatinine testing; 3 days post
surgery hospitalization, as well as postoperative follow-up Visits. Postoperative services
to include wound checks, and exams in clinic, and dilation teaching with vaginal dilators,
This package price does not include any take home medications or supplies, pathology
or lab outside of description above, radiology, or treatment for postrsurgery
complications, if such services are required.

Procedure Price
Penile Inversion Vaginoplasty $20,080.00

Prepayment for this procedure is required by end of business day Thursday
12/21/2017. If prepayment is not received within the timeframe required, your
procedure will be cancelled. We will re-schedule once payment has been received.
Payment may be made by cashier's check or maior credit card.

Please do not hesitate to Contact our oflice if you have further questions I look
forward to speaking with you.

Trianna Schubert
Community Care Specialists