Registration Information

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

Physician Name:
Is this your GP:  Yes   No
Address:
Telephone:

Other Information

How did you here 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 breast feeding?                                Yes   /   No 
Have you ever had an issue with anaesthesia?                Yes   /   No
Smoking Non-Smoker      Smoker (Quantity?):
Recreation 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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CENTRE FOR ADVANCED FACIAL COSMETIC & PLASTIC SURGERY - Julian De Silva M.B.B.S, M.D.

Covid-19 Update

Through the new phase of restrictions in the United Kingdom, The Centre London will remain open for patients. We are proud to offer our services in a CQC registered clinical environment, with strict COVID hygiene and safety protocols. Our Team will contact you should your appointment need to be changed, otherwise, we look forward to seeing you at 23 Harley Street.