I authorize: To use and disclose a copy of the specific health information described below:
✓ History and physical examinations✓ Consultation reports✓ Laboratory reports✓ Operative reports✓ Discharge summary✓ X-ray/Diagnostic images✓ Other, specify below.
To: LEFNY CONSULTANT, LLCAttn: 3405 PUTNAM PLACE, STE # B2BRONX 10467 NY United StatesPhone (+1) 646 5739477
If the information to be disclosed contains any of the types of records or information listed below, additional laws regarding the use and disclosure of the information may apply. I understand and accept that this information will be disclosed, so I will proceed to fill in the following fields with my data as a sign of agreement.
This authorization is voluntary and you may refuse to sign this authorization. Refusal to sign this authorization will affect your ability to participate in this care coordination program and failure to disclose any of the above conditions may result in cancellation of the surgery.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. Any use or disclosure that has already been made with your permission cannot be undone.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer protected by federal law. However, I also understand that federal or state law may restrict the release of HIV/AIDS information, mental health information, drug/alcohol diagnosis, treatment, or referral information.
I understand that my health information may be shared with health care providers, nurse case managers, health advocates, and other professionals who have currently been or will be involved in my care in order to better coordinate my care.
I have read this authorization and I understand it. Unless revoked, this authorization does not expire.
I declare that the information I will provide is accurate and complete about me.
CONTACT: contact us via email at [email protected]
This is an agreement (“Agreement”) between you as an individual (“You”) and Lefny Consultant Llc (“LEFNY ”). LEFNY CONSULTANT, LLC provides for the coordination of travel accommodations and medical treatment provided by third-party providers (“Services”). The term “You” refers to the individual using the Service. The Services are offered to you conditioned upon your acceptance of the terms, conditions, and notices set forth below. By accessing or using the Services, you agree to be bound by this Agreement and represent that you have read and understood its terms. Please read the agreement carefully, as it contains information concerning your legal rights and limitations of these rights, as well as a section regarding applicable law and jurisdiction of disputes.
By completing the form and clicking the Submit button, you agree to all the terms and conditions of this Agreement. If you do not accept all the terms and conditions, you are not authorized to use the Services, and you should not click the Submit button.“Services” as defined above refers to those provided by Lefny Consultant Llc. The Services are provided solely to:
We may change or otherwise modify this Agreement in the future in accordance with the terms and conditions herein, and you understand and agree that your continued access or use of the Services after the change signifies your acceptance of the updated or modified Agreement.
USE of the ServicesAs a condition of your use of the Services, you warrant that (i) all the information supplied is true, accurate, current, and complete. You are required to make reservations in the name listed on Your government documents used for travel and if you need to make changes to a name after travel documents have been issued, You are responsible for all applicable fees (ii) you possess the legal authority to enter into this Agreement and to use the Services in accordance with all terms and conditions herein.We retain the right at our sole discretion to deny anyone access to the Services, at any time and for any reason, including but not limited to, for violation of this Agreement.
BOOKING with Third-party SUPPLIERS through Lefny Consultant LlcLefny Consultant Llc offers you the ability to search for, select, and book travel reservations and medical appointments with third-party suppliers. By booking via the website, you agree that you will use the LEFNY CONSULTANT LLC website only to make legitimate reservations for you or others for whom you are legally authorized to act. Any false or fraudulent reservation is prohibited.
As a user of the Services, you understand that: (1) LEFNY CONSULTANT LLC will not have any liability to you or others for any unauthorized transactions made using your password or account; and (2) The unauthorized use of your password or account could cause you to incur liability to LEFNY CONSULTANT LLC.
LEFNY CONSULTANT LLC will not interfere with reservations arbitrarily but reserves the right to withdraw booking facilitation service because of certain extenuating circumstances, such as when a reservation is no longer available or when we have reasonable cause to suspect that a booking request may be fraudulent. Lefny Consultant Llc also reserves the right to take steps to verify your identity to process your booking request.
Third-Party Suppliers. Lefny Consultant Llc is not a medical provider and does not own or operate medical facilities or provide medical care. Although LEFNY CONSULTANT LLC displays information about services offered by third-party suppliers and facilitates reservations with certain suppliers on or through Lefny Consultant Llc’s website, such actions do not in any way imply, suggest, or constitute Lefny Consultant Llc’s sponsorship or approval of third-party suppliers, or any affiliation between Lefny Consultant Llc and third-party suppliers. Although You may review particular services or accommodations, LEFNY CONSULTANT LLC does not endorse or recommend the products or services of any third-party suppliers. You agree that LEFNY CONSULTANT LLC is not responsible for the accuracy or completeness of the information obtained from third-party suppliers regarding the Services.
Your interactions with third-party suppliers are at your own risk. LEFNY CONSULTANT LLC will have no liability with respect to the acts, omissions, errors, representations, breaches, or negligence of any third-party suppliers or for any personal injuries, death, property damage, or other damages or expenses resulting from your interactions with third-party suppliers.
TRAVEL DESTINATIONSInternational Travel. When you book international travel reservations with third-party suppliers or plan international trips using the LEFNY CONSULTANT LLC website, you are responsible for ensuring that you meet all foreign entry requirements and that your travel documents, including passports and visas, are in order.For passport and visa requirements, please consult the relevant embassy or consulate for information. Because requirements may change at any time, be sure to check for up-to-date information before booking and departure. LEFNY CONSULTANT LLC does not accept liability for travelers who are refused entry onto a flight or into any country because of the traveler’s failure to carry the travel documents required by any airline, authority, or country, including countries the traveler may just be passing through an route to his or her destination.
It is also your responsibility to consult your physician for current recommendations on inoculations before you travel internationally and to ensure that you meet all health entry requirements and follow all medical guidance related to your trip.
Although most travel, including travel to international destinations, is completed without incident, travel to certain destinations may involve greater risk than others. LEFNY CONSULTANT LLC urges travelers to investigate and review travel prohibitions, warnings, announcements, and advisories issued by their own governments and destination country governments prior to booking travel to international destinations.
You are responsible for ensuring that you have the proper travel documents and MUST CHECK with the respective consulate(s) or a visa agency to determine whether any visas or passports are required. Passports are required to be valid for at least 6 months after the date of travel. Some countries require a full blank “VISA” page in the passport for stamping purposes. Any information provided on travel description pertains to US citizens only. Non-US citizens should check with the respective consulate of the country(s) to be visited for current entry requirements.
By listing information relevant to travel to particular international destinations, LEFNY CONSULTANT LLC does not represent or warrant that travel to such locations is advisable or without risk and is not liable for damages or losses that may result from travel to such destinations.
MEDICAL TRAVEL PROTECTION: You will be required to have medical travel protection to cover any surgical or medical procedure related to the Services. You have the option of purchasing additional medical insurance that will provide coverage for approximately 6 months and such information will be provided upon request.
PAYMENTS & CANCELLATION
DEPOSIT: A deposit is due at the time of booking of the Services. All deposits are non-refundable and non-transferrable.
PAYMENTS: Once you select the Service, and submit your deposit to reserve your Service appointments, you will be sent an online invoice directing you to pay the amount due online. The balance due is payable with most major debit or credit cards, PayPal, and by bank transfer. Full payment is due within 30 days prior to the date of the scheduled Service. If full payment is not received 30 days prior to the scheduled date of the Services, you are required to pay the remainder of your balance in United States Dollars directly to the Lefny Consultant Llc facility upon your arrival. You will be provided the designated place to pay the remaining balance prior to your arrival. The deposit will be deducted from the full cost of the Service. The cost of the Service is non-refundable, and the balance is due 30 days prior to the scheduled date of the Service. The total cost of the Service is non-negotiable, and the final costs are subject to change.
FORM OF PAYMENT: Major credit cards, PayPal, bank transfers, and debit cards can be used as payments for the Service. You are responsible for all payments, and You will be charged a $50 service fee for all dishonored transactions. You are responsible for all credit card, wire transfer, and international transaction fees.
By clicking “Enter Payment", and subsequently submitting your card or other payment information to us, you agree to pay the entire Payment Amount for the Services selected and authorize us to charge your designated payment method for such Payment Amount. You may be required to provide documentation or proof of payment.
PRIOR TO ARRIVAL
The amounts of the services are not refundable or transferable, likewise the reservation amounts with the chosen doctor are not transferable or refundable.The reservation is valid for one year.
Once a deposit has been made, cancellations will be accepted up until 2 weeks before the scheduled date of the Services. YOUR DEPOSIT IS NON-REFUNDABLE.In case of a medical issue that prevents you from having surgery, you may be entitled to a refund for part of the Services. Contact third-party providers directly for refunds, as refunds will not be issued by Lefny Consultant Llc. In case of cancellation of surgery before departure, you may be entitled to a refund. Please allow 7-30 days for a refund to be reflected in your account.
Jurisdiction and governing lawThis Agreement and any dispute or claim (including non-contractual disputes and claims) arising out of or in connection with its subject matter or formation shall be governed by and construed in accordance with the laws of Westchester County, New York. You hereby consent to the exclusive jurisdiction and venue of courts in Westchester County, New York. Nothing in this clause should limit the right of LEFNY CONSULTANT LLC to take proceedings against you in any court of competent jurisdiction.
ARBITRATION: You agree to submit to Arbitration any and all disputes concerning the enforcement of the Agreement or disputes related to the Services pursuant to the comprehensive arbitration rules & procedures of the Judicial Arbitration and Mediation Services, Inc. (JAMS). You further agree that You will bear the costs for submission to arbitration, including but not limited to, paying half the initial arbitration fee and the arbitrator’s fees. The Arbitration will be governed by substantive (but not procedural) New York law and will take place in New York, NY. By agreeing to these terms and conditions, you are waiving your right to a trial by jury. Nothing in this clause should limit the right of LEFNY CONSULTANT LLC to take proceedings against you in any court, or courts of competent jurisdiction.
PLEASE READ THIS SECTION CAREFULLY. THIS SECTION LIMITS Lefny Consultant Llc’s LIABILITY TO YOU FOR ISSUES THAT MAY ARISE IN CONNECTION WITH YOUR USE OF THE SERVICES. IF YOU DO NOT UNDERSTAND THE TERMS IN THIS SECTION OR ELSEWHERE IN THIS AGREEMENT, PLEASE CONSULT A LAWYER FOR CLARIFICATION BEFORE USING THE SERVICES.
THE INFORMATION PROVIDED REGARDING THE SERVICES MAY INCLUDE INACCURACIES OR ERRORS, INCLUDING RESERVATION AVAILABILITY AND PRICING ERRORS. Lefny Consultant Llc DOES NOT GUARANTEE THE ACCURACY OF AND DISCLAIMS ALL LIABILITY FOR, ANY ERRORS OR OTHER INACCURACIES RELATING TO THE INFORMATION AND DESCRIPTION OF THE SERVICES. IN ADDITION, Lefny Consultant Llc EXPRESSLY RESERVES THE RIGHT TO CORRECT ANY AVAILABILITY AND PRICING ERRORS.
Lefny Consultant Llc MAKES NO REPRESENTATIONS OF ANY KIND ABOUT THE SUITABILITY OF THE SERVICES, INCLUDING THE INFORMATION CONTAINED ON ITS WEBSITES OR ANY PORTION THEREOF, FOR ANY PURPOSE, AND THE INCLUSION OR OFFERING OF ANY PRODUCTS OR SERVICE OFFERINGS ON ITS WEBSITES OR OTHERWISE THROUGH THE SERVICES DOES NOT CONSTITUTE ANY ENDORSEMENT OR RECOMMENDATION OF SUCH PRODUCTS OR SERVICE OFFERINGS BY Lefny Consultant Llc. ALL SUCH INFORMATION AND SERVICE OFFERINGS MADE AVAILABLE BY OR THROUGH THE SERVICES ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
THE THIRD-PARTY SUPPLIERS PROVIDING THE SERVICES ARE INDEPENDENT CONTRACTORS AND NOT AGENTS OR EMPLOYEES OF Lefny Consultant Llc. LEFNY CONSULTANT LLC IS NOT LIABLE FOR THE ACTS, ERRORS, OMISSIONS, REPRESENTATIONS, WARRANTIES, BREACHES, OR NEGLIGENCE OF ANY SUCH SUPPLIERS OR FOR ANY PERSONAL INJURIES, DEATH, PROPERTY DAMAGE, OR OTHER DAMAGES OR EXPENSES RESULTING THEREFROM.
SUBJECT TO THE FOREGOING, YOU USE THE SERVICES AT YOUR OWN RISK AND IN NO EVENT SHALL Lefny Consultant Llc (OR THEIR OFFICERS, DIRECTORS AND/OR EMPLOYEES) BE LIABLE FOR ANY DIRECT, INDIRECT, PUNITIVE, INCIDENTAL, SPECIAL, OR CONSEQUENTIAL LOSSES OR DAMAGES OR ANY LOSS OF INCOME, PROFITS, GOODWILL, DATA, CONTRACTS, USE OF MONEY, OR LOSS OR DAMAGES ARISING FROM OR CONNECTED IN ANY WAY TO BUSINESS INTERRUPTION OF ANY TYPE ARISING OUT OF, OR IN ANY WAY CONNECTED WITH, YOUR ACCESS TO, DISPLAY OF OR USE OF THE SERVICES OR WITH THE DELAY OR INABILITY TO ACCESS, DISPLAY OR USE THE SERVICES (INCLUDING, BUT NOT LIMITED TO ANY VIRUSES, BUGS, TROJAN HORSES, INFORMATION, SOFTWARE, LINKED SITES, PRODUCTS, AND SERVICES OBTAINED THROUGH THE SERVICES; PERSONAL INJURY OR PROPERTY DAMAGE, OF ANY NATURE WHATSOEVER, RESULTING FROM YOUR USE OF THE SERVICES’ SERVERS AND/OR ANY AND ALL PERSONAL INFORMATION AND/OR FINANCIAL INFORMATION STORED THEREIN; ANY ERRORS OR OMISSIONS IN ANY CONTENT OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF THE USE OF ANY CONTENT; OR OTHERWISE ARISING OUT OF THE ACCESS TO, DISPLAY OF OR USE OF THE SERVICES) WHETHER BASED ON A THEORY OF NEGLIGENCE, CONTRACT, TORT, STRICT LIABILITY, OR OTHERWISE, AND EVEN IF LEFNY CONSULTANT LLC OR ITS AFFILIATES HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
If Lefny Consultant Llc or its affiliates are found liable for any loss or damage that arises out of or is in any way connected with your use of the Services, then the liability of Lefny Consultant Llc or its affiliates will in no event exceed, in the aggregate, the greater of (a) the transaction fees paid to Lefny Consultant Llc for the transaction(s) on or through the Services giving rise to the claim, or (b) One-Hundred Dollars (the US $100.00).
THESE TERMS AND CONDITIONS AND FOREGOING LIABILITY DISCLAIMER DO NOT AFFECT MANDATORY LEGAL RIGHTS THAT CAN NOT BE EXCLUDED UNDER APPLICABLE LAW, FOR EXAMPLE UNDER CONSUMER PROTECTION LAWS IN PLACE IN CERTAIN COUNTRIES.
ASSUMPTION OF RISK: You are aware that your participation in the Services involves hazardous activities, with a risk of illness, injury, or death which may be caused by forces of nature, animals, insects, or flora or other persons and companies known or unknown, or of the willful or criminal conduct of third-parties. You are aware that weather conditions may be severe, adverse, and/or unpleasant. You are also aware that medical services or facilities may not be readily available or accessible during some or all of the time during which You are participating in the Services. You agree to accept the risks and uncertainty involved in taking part in the Services and accept and assume full responsibility for any and all risks of illness, injury, or death.You understand the physical requirements of participating in the Services and do not have any known physical, medical, or mental condition which would impair your ability to participate in the Services. You authorize LEFNY CONSULTANT LLC its affiliates, and third-party providers to arrange for any emergency medical treatment and hospitalization as may be necessary without your consent.
IndemnificationYou agree to defend and indemnify LEFNY CONSULTANT LLC and any of their officers, directors, employees, and agents from and against any claims, causes of action, demands, recoveries, damages, fines, losses, penalties, or other costs or expenses of any kind or nature including but not limited to reasonable legal and accounting fees, brought by third parties as a result of:
Modifications to the services; terminationLEFNY CONSULTANT LLC may change, add, or delete these terms and conditions of this Agreement or any portion thereof from time to time in its sole discretion where we deem it necessary for legal, general regulatory, and technical purposes, or due to changes in the Services provided or nature or layout of Services. Thereafter, you expressly agree to be bound by the terms and conditions of this Agreement as amended.LEFNY CONSULTANT LLC may change, suspend, or discontinue any aspect of the Services at any time, including the availability of any of the Services’ features or databases. Your continued use of the services now or following the posting of any such notice of any changes will indicate acceptance by you of such modifications.
LEFNY CONSULTANT LLC may terminate this Agreement with you at any time, without advance notice, where it believes in good faith that you have breached this Agreement or otherwise believes that termination is reasonably necessary to safeguard the rights of LEFNY CONSULTANT LLC and/or other users of the Services. We reserve the right to stop providing you with the Services.
General ProvisionsYou agree that no joint venture, agency, partnership, or employment relationship exists between You and LEFNY CONSULTANT LLC and/or its corporate affiliates as a result of this Agreement or use of the Services.Deposit amounts are based on the Service and may exceed $600.
Our performance of this Agreement is subject to existing laws and legal processes, and nothing contained in this Agreement limits our right to comply with law enforcement or governmental or legal requests or requirements relating to your use of the Services or information provided to or gathered by us with respect to such use. To the extent allowed by applicable law, you agree that you will bring any claim or cause of action arising from or relating to your access or use of the Services within two (2) years from the date on which such claim or action arose or accrued or such claim or cause of action will be irrevocably waived.
If any part of this Agreement is determined to be invalid or unenforceable pursuant to applicable law including, but not limited to, the warranty disclaimers and liability limitations set forth above, then the invalid or enforceable provision will be deemed superseded by a valid, enforceable provision that most closely matches the intent of the original provision and the remaining provisions in this Agreement shall continue in effect.
This Agreement (and any other terms and conditions referenced herein) constitutes the entire agreement between you and LEFNY CONSULTANT LLC with respect to the Services and it supersedes all prior or contemporaneous communications and proposals, whether electronic, oral, or written between you and LEFNY CONSULTANT LLC with respect to the Services.
You understand that LEFNY CONSULTANT LLC does not provide medical care or treatment and that LEFNY CONSULTANT LLC only coordinates travel and medical services.You understand that the Physicians, Anesthesiologists, and other medical professionals who may participate in the Services are Independent Contractors and are not employees or agents of LEFNY CONSULTANT LLC.You agree to allow LEFNY CONSULTANT LLC to pay all providers of Services on your behalf.
VOLUNTARY PARTICIPATION: You acknowledge that You are voluntarily participating in the Services with knowledge of the danger involved, and hereby agree to accept and assume all risks of property damage, personal injury, or death. You also acknowledge that You voluntarily applied to participate in the Services described in this Agreement and that You have read the description of the trip as it appears on the website www.LEFNY international.com along with all information contained in this application.
PHOTOGRAPHIC RELEASE: You agree to allow LEFNY CONSULTANT LLC to take photographs of you and use your likeness in a photograph, video, or other digital media in any of its publications, including web-based publications and promotional and commercial use without any compensation to you.
USE OF WEBSITES: https://lefnyconsultant.com, Agreement between Customer and LEFNY CONSULTANT LLC is offered to you, the customer, conditioned on your acceptance without modification of the terms, conditions, and notices contained herein. Your use of https://lefnyconsultant.com constitutes your agreement to all such terms, conditions, and notices.
You acknowledge that you are healthy enough to participate in the Services. You also agree that you have consulted with your Primary Care Physician prior to your decision to participate in the Services. You agree that you have received the required laboratory tests prior to engaging in the Services. You agree that your laboratory ranges and BMI are within the ranges provided by Lefny Consultant Llc.
I agree to the service agreement terms & conditions. I understand all payments to LEFNY CONSULTANT LLC are non-refundable and non-transferrable. I further acknowledge that I have been advised to purchase travel insurance to protect my investment.
PLEASE USE THE GUIDELINES BELOW TO ENSURE THAT THE PHOTOS YOU SUBMIT ARE ACCEPTED BY ALL OUR DOCTORS AND SERVICE PROVIDERS.
BREAST SURGERY PHOTOS:
For clients requesting any type of Breast Surgery, the following additional requirements are needed for our surgeons to make a more informed decision on suitability as a candidate for surgery.
The front view includes the neck, shoulders, breasts, and navel.
Front view with both arms raised above the head.
Front view with both arms raised above the head, body leaning or slightly bent forward assuming a diving position.
Left and Right Side view with both arms down the side, as if standing to attention.
Left and Right Side view with both arms raised above the head, body leaning forward or slightly bent forward assuming a diving position.
FACIAL PHOTOS MUST INCLUDE:
Head Tilted Backwards
Head Tilted Downwards
RHINOPLASTY PHOTOS MUST INCLUDE:
TUMMY TUCK PHOTOS MUST INCLUDE:
THIGH LIFT PHOTOS MUST INCLUDE:
Left Profile – Showing Inside Thigh
Right Profile – Showing Inside Thigh
Left Profile – Showing Outside Thigh
Right Profile – Showing Outside Thigh
ARM PHOTOS MUST INCLUDE:
Left Arm Raised At Side Of Body
Right Arm Raised At Side Of Body