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Registration Form

Registration Information

Patient name:
Date of birth:
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

Physician Name:
Is this your GP:  Yes   No

Other Information

How did you hear about us:
Any other relevant information:

Patient Medical History

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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