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PATIENT FORMS & INFO
Prior to Surgery
Patient Intake Form
Medical History Form
Intake Form (pdf)
Contact Us
Enter your Full Names
Contact Number
Email
Do you have any of the following conditions?
Allergies
Anaemia
Arthritis
Asthma
Bleeding Disorder
Cancer
Diabetes
Gallbladder Problem
Glaucoma
Heart Disease
Heart Murmur
High Blood Pressure
Kidney Conditions
Liver Problems
Lung Condition
Prostate Problems
Rheumatic Fever
Sinus Infection
Seizures-Epilepsy
Stroke
Stomach Problems
Thyroid Condition
Tuberculosis (TB)
List other serious illnesses
Do you have any allergies (e.g. drugs, food, antibiotics, dyes, local anaesthetic
Yes
No
If yes, please list
Has your weight changed in the past year?
Yes
No
Please list all your current medicines and remedies you take, including dose
Do you take any blood-thinning medication?
None
Asprin
Warfarin
Ecotrin
Xarelto
Herbal
Other
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