Name: Surname: Gender (M, F)
--
M
F
Date of birth: Weight :
Kg
lbs
Height:
m
ft
Address: Address: Post code: Tel day: Tel evening : Email address : secret question :
Please Select
Best Holiday
Favourite Food
Favourite Book
Favourite Song
secret answer : For data protection purpose, and to keep all your future phone communication with us confidential, you need to provide a secret question and a secret answer.
When you call the flying patient.com in the future you will be asked
to provide the secret question and answer or a reference number that will
be sent to you after the submission of this form
Your email address is
considered as a confidential mean of communicating with the flyingpatient.com
staff.
Orthopaedic Surgery:
Please Select
Right Total Knee Replacement
Left Total Knee Replacement
Right Total Hip Replacement
Left Total Hip Replacement
Cosmetic Surgery:
Please Select
Hair Transplant
Eye Lid Lift
Breast ReductionLlift
Breast Enlargement
Face Lift
Rhinoplasty
Abdominoplasty
Liposuction
Hair Transplant
For cosmetic surgery please attach photographs ( front and the two sides : right and left) of the area of your body to be treated.
General surgery:
Name : Surname : Relationship :
Tel Day : Tel Evening: Address: Postcode : Do you smoke
--
Y
N
If yes, how many cigarettes per day Do you drink alcohol
--
Y
N
If yes, how many units per day? Do you suffer from any allergy to medication, food or any other products
--
Y
N
If yes , please list them. Do you suffer from diabetes .
--
Y
N
Do you suffer or ever suffered from asthma, pneumonia or bronchitis?
--
Y
N
If yes, specify. Do you have any heart condition ?
--
Y
N If yes specify Do you suffer from high blood pressure ?
--
Y
N
If yes what medication are you taking ? Do your suffer from kidney disease
--
Y
N
If yes specify : Do you suffer from liver or spleen disease
--
Y
N
If yes specify Do you suffer from any disease not mentioned here ( Y,N)
--
Y
N
If yes specify Have you had any surgery in the past
--
Y
N
If yes, specify kind of surgery and when? Have you had any reaction to anaesthetic in the past
--
Y
N
If yes, specify the kind of reaction Are you taking any medication
--
Y
N
If yes, list your medication here. Questions you would like to ask your surgeon This form will be submitted to your hospital In Tunisia.
All the information supplied here is strictly
confidential , it will
be used by the staff at the flying patient .com to support you and supply
you with the information you need before and after surgery but
it will
be mainly for use by your surgeon to give him a general idea
about your medical history, before he see you personally on your first
free consultation
on your arrival to Tunisia.
From the information supplied here,
your surgeon can give some instructions to prepare you for your
surgery prior
to your travel , like stop smoking, stop drinking alcohol,
taking some vitamins or other supplements, checking your teeth
with your dentist,
taking shower with antiseptic shower gel...
You might also be asked to
carry out some tests before you travel to Tunisia.
Please accept our Terms and Conditions Submit
