Elite Surgical
0800 001 6688
info@elitesurgical.co.uk

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Home » Medical Form

Medical Form

Step 1 of 11

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  • PATIENT INFORMATION

  • Please Specify
  • GP DETAILS

  • ADDITIONAL INFORMATION

    If you are under the care of any other health care professional e.g. specialist doctor, ophthalmologist, or psychiatrist, please provide details below.
  • PATIENT HEALTH QUESTIONAIRE

    Do you or have you had any of the following?

  • Please specify
  • Allergies and Sensitivities

  • Confirmations

  • PATIENT'S MEDICATION QUESTIONNAIRE

  • Are you taking / using any of the following?

  • Please note: If you are having any of the following procedures, HRT and COC must be stopped 4 weeks pre-operatively and recommenced 2 weeks post operatively.

    1. - Abdominoplasty - Arm Lift
    2. - Abdominoplasty with liposculpture - Thigh Lifts
    3. - Breast Reduction - Lower Body Lifts
    4. - Mastopexy with Implants - Face Lifts
    5. - 3 Or More Areas of Lipo

    • Patients may continue to take their COC/HRT for all other planned procedures.
    • Patients may continue with their mini pill, depot vera, and merina coil for all planned procedures
    • Patients taking any slimming aids, e.g. Reductil, must stop taking them 10 days preoperatively.
    • Patients with a gastric band must have their band aspirated 2 weeks pre-operatively.
    • Patients must stop smoking for 4 weeks prior to all surgery.
    • Any cosmetic eye surgery requires a current eye test certificate, dated within a year of surgery.
    • Patients in groups known to be at risk of sickle cell disease are required to provide a current test result at least 1 week before surgery.
  • Medication

  • As a process of pre-admission we may need to request documentation from your GP or other health care provider. Wherever necessary, we would appreciate if you could forward any medical test results you have received in the last 6 months directly to your patient care co-ordinator or the clinic nurse marked for the attention of Pre-Operative assessment nurse office.

  • Part 1

    PATIENT CONSENT FOR THE RELEASE OF MEDICAL INFORMATION FROM GP OR MEDICAL SPECIALIST & EMERGENCY CONTACT WITH GP

  • hereby consent for information to be released from my medical notes as requested by Elite Surgical in relation to any forthcoming surgery I may wish to have undertaken. I take full responsibility in settling any fees this service may incur. I give my consent for the release of medical information to Elite Surgical in the event of an emergency.

  • Part 2

    PATIENT DISCLAIMER

    ALL PATIENTS MUST COMPLETE THIS SECTION

    I can confirm that the medical history contained in this document is accurate and complete. I understand that withholding any medical information will be detrimental to my health and safety during any procedure that the surgeon agrees to undertake. My procedure is subject to the surgeon’s consultation and medical clearance. I can confirm I have received and understood and agree to the Terms & Conditions of Elite Surgical and I have been a copy of these.

  • CHAPERONE RECORD

  • Please complete the relevant section below to confirm that the provision of a chaperone has been discussed with the patient and the outcome of the discussion

  • Details of Chaperone

  • hereby give my consent for my Surgeon / Elite Surgical to take my clinical (pre and post-operative) photographs and for these to be used as part of my clinical records (this is a mandatory requirement as part of your medical records). I also consent for my clinical photographs to be used at the discretion of my Surgeon/Elite Surgical as follows (please delete as appropriate, you can withdraw your consent at any time by advising us in writing.*):-

    • For patient education purposes
    • For publication on Elite Surgical Website/Social Media/Print Media
    (Please be assured that identifiable features will be obscured i.e. eyes blacked out etc)

  • Elite Surgical - Body Dysmorphic Disorder Questionnaire (BDDQ) (Confidential – Please Complete)

    This questionnaire asks about concerns with physical appearance. Please read each question carefully and circle the answer that is true for you. Also write in answers where indicated.

  • If you answered "NO" to either of the above questions, then you are finished with this questionnaire. Otherwise please continue.

  • 3) How has this problem with how you look affected your life?

  •  

    END

     

    Thank you for completing this form.

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