Registration Information |
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| Patient name: | |
| Gender: | |
| Date of birth: | |
| Address: | |
| Email address: | |
| Home telephone number: | |
| Mobile/work telephone number | |
| May we leave messages on your answering machine? May we contact you by post? |
Yes No Yes No |
| Name of next of kin or emergency contact: | Telephone: |
| Social: Do you have someone to take care of you after your surgery? | Yes No |
General Practitioner Physician or Primary Care Information |
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| Physician Name: Is this your GP: Yes No |
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| Address: | |
| Telephone: | |
Other Information |
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| How did you hear about us: | |
| Any other relevant information: | |
Patient Medical History |
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| How is your general health, any current issues? | |
| Past medical conditions: | |
| Past surgical conditions: | |
| Family conditions: | |
| Please list any current medications: | |
| Any allergies to medications: | |
| Please list any herbal medications:(e.g. vitamin supplements, St.John’s Wort, fish oils, garlic, ginseng) | |
| Have you ever had any of the following illnesses? Psychiatric illness or depression
Heart problems Jaundice or hepatitis Melasma or skin pigmentation of the face Eczema, acne or other skin condition Cold sores Keloid scarring Easy bruising HIV or Hepatitis B |
Yes / No
Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No |
| Are you pregnant or breastfeeding? Yes / No | |
| Have you ever had an issue with anaesthesia? Yes / No | |
| Smoking: Non-smoker Smoker (quantity?): | |
| Recreational drug use: No Yes (which & quantity?): | |
| Any relevant professional information? | |
| Any special hobbies? | |
| Other relevant information? | |
| Do you take any of the following medications? Warfarin Plavix Aspirin NSAIDs
Date of most recent physical examination: |
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Renowned expert in Facial Cosmetic and Plastic Surgery. Signature techniques in Blepharoplasty, Rhinoplasty and Facelift surgery. Expert in revision surgery and in natural looking results
