Patient Information

Prior to your procedure taking place it is necessary to obtain an accurate and detailed medical history. Please complete the following document to the best of your knowledge providing as much detail as possible.

Please add these photos angles to the form for Dr Nurein to review before your free consultation.

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Please answer all of the following questions

Next of Kin Details (we can contact)

Patient Health Questionnaire

Please complete the following health questionnaire. Answer ALL questions

Do you have any of the following?

Medication

Please note, patients on beta blockers may be asked to stop them 1-2 weeks pre-op

Allergies and Sensitivities

Please tick each statement to confirm that you have understood it.

GDPR Consent

As per the latest GDPR regulations, we are obligated to obtain your explicit written consent to be able to contact you and share your personal details with the clinic or hospital where we are consulting and performing your procedure (we will use only the above given details to contact you unless stated otherwise).

It is good practice that we inform your GP but if you cannot provide their details we will provide you with a letter to give to your GP. If you are under the care of any other health care professional please provide full details below.

Current Health Practitioner Details

Proving an email / this field is mandatory
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