8920 Wilshire Blvd.

Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
PLASTIC SURGERY
I hereby request surgical privileges in the specialty of Plastic Surgery as shown
in this form. I understand that privileges granted are subject to a bi-annual
review coinciding with reapplication for medical staff membership. I also
understand that application for additional or new procedures can be made at any
time with proper documentation.
Please indicate with an X in the appropriate bo! and by signature at the end of
this document the procedures you are requesting privileges for.
"ocumentation of training and e!perience is attached for those procedures mar#ed
by an asteris# $%& and those procedures that are outside of your original
specialty training.
'pplied for 'pproved
HEAD & NECK SURGERY
Plastic repair of mouth and lip ()S *+
,econstruction of soft tissues of face- head and
*ec#
()S *+
EYE SURGERY
.lepharoplasty ()S *+
"ilatation or repair of lacrimal eyelid ()S *+
Plastic repair of eyelid ()S *+
EAR SURGERY
'esthetic / reconstructive ear surgery ()S *+
+toplasty ()S *+
0raumatic repair ()S *+
NOSE & THROAT SURGERY
*asal septum-submucous resection and1or septoplasty ()S *+
Sinus surgery ()S *+
0urbinate surgery 2 conventional or 30P 4aser ()S *+
BREAST SURGERY
'bscess I / " ()S *+
'esthetic / ,econstructive ()S *+
.iopsy ()S *+
5apsulectomy ()S *+
6ynecomastia ()S *+
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
7astectomy- simple or subcutaneous ()S *+
7astope!y- reduction mammoplasty w1 or w1o implant ()S *+
Plastic procedures $e.g.- reconstruction mammoplasty-
augmentation- reduction&
()S *+
,e-implantation ()S *+
NEUROLOGICAL SURGERY
*erve repair- resection and transfer or grafts
$peripheral&
()S *+
INTEGUMENTARY SURGERY
,epair of superficial lacerations ()S *+
I/" of superficial abscesses ()S *+
)!cision of superficial benign cysts- lipoma or tumors ()S *+
,emoval of superficial 8...s ()S *+
)!cision of cancer of s#in ()S *+
)!cision of pilonidal fistula or cyst ()S *+
S#in resection ()S *+
,econstruction w1 flap and1or w1 graft ()S *+
HAND SURGERY
'mputation of fingers or dislocations ()S *+
,epair of graft of nerves ()S *+
'rthrodesis ()S *+
"islocations- hand 2 open reductions ()S *+
,epair tendons ()S *+
,econstruction of soft tissues ()S *+
,epair of severed tendon ()S *+
"islocations- hand 2 closed reduction only ()S *+
9ncomplicated fractures 2 closed reduction only ()S *+
5omple! fracture- hand 2 closed reduction ()S *+
8ractures- hand 2 internal fi!ation ()S *+
,elease of "upuytren:s contractures ()S *+
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
GRAFT
Small areas $; diameter or less& ()S *+
.one ()S *+
5artilage ()S <
S#in ()S *+
8at ()S *+
FLAPS
Immediate ()S *+
"elayed ()S *+
7yocutaneous ()S *+
S#in ()S *+
8asciocutaneous ()S *+
BIOPSY
S#in ()S *+
7uscle ()S *+
4ymph nodes ()S *+
.ones ()S *+
8at ()S *+
*erve ()S *+
0endon ()S *+
UROGENITAL
'esthetic / reconstructive ()S *+
OTHER
S#in cancer surgery ()S *+
Surgery for congenital deformities including cleft lip-
cleft palate
()S *+
7a!illofacial injuries- reduction / fi!ation ()S *+
.reast surgery including total mastectomy- augmentation-
reduction- and reconstruction
()S *+
Surgery for congenital and acquired deformities of the
hands including acute trauma
()S *+
,econstructive operations involving s#in- fat- dermis-
bone- and cartilage grafts and s#in flaps and myocutaneous
()S *+
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
flaps
AESTHETIC SURGERY
8at transfer ()S *+
,hytidoplasty $face lift& ()S *+
.lepharoplasty ()S *+
6enioplasty ()S *+
+toplasty ()S *+
'ugmentation 7ammoplasty ()S *+
,hytidectomy $all areas& ()S *+
Suction assisted lipectomy $all areas& ()S *+
,hinoplasty ()S *+
%)ndoscopic .row 4ift ()S *+
'bdominal dermolipectomy w1 or w1o repair diastasis recti ()S *+
9mbilical herniorraphy ()S *+
=entral herniorraphy ()S *+
8acial resurfacing ()S *+
5hemical Peel ()S *+
"ermabrasion ()S *+
Injection $.oto!- 5ollagen- "ermologen& ()S *+
LASER SURGERY
%30P 4aser ()S *+
%5+
>
4aser ()S *+
%)rbium ()S *+
%*d?('6 4aser ()S *+
%=ersapulse1pulsed dye laser ()S *+
%+ther 4aser? ()S *+
Radiograph U!" o# Moda$i% & i&%"rpr"%a%io& o# i'ag"!
(%h"rap")%i* a&d diag&o!%i*+
()S *+
U$%ra!o)&d U!" o# Moda$i% & i&%"rpr"%a%io& o# i'ag"!
(%h"rap")%i* a&d diag&o!%i*+
()S *+
F$)oro!*op U!" o# Moda$i% ,i%h S%a%" Li*"&!" &
i&%"rpr"%a%io& o# i'ag"! (%h"rap")%i* a&d diag&o!%i*&
()S *+
8920 Wilshire Blvd.
Suite 101
Beverly Hills, CA 90211
(310) 360-9119 phn
(310) 360-9115 fax
Applicants Nae
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Lo*a$ a&"!%h"!ia ()S *+
Co&!*io)! S"da%io& ()S *+
S)p"r-i!io& o# Co&!*io)! S"da%io& Trai&"d R"gi!%"r"d
N)r!"
()S *+
+0@),S *+0 4IS0)"
()S *+
()S *+
()S *+

Signature of 'pplicant "ate

Signature of AI committee chairperson "ate recommended

Signature of 6overning .ody chairperson "ate recommended