Evolution Cosmetic will forward your medical details to your selected surgeon who will reply with his basic clinical evaluation and any relevant detaqils as soon as possible.
Please Note: For this enquiry to reach us you must provide a valid email address.
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW
Please be assured that all electronic data received is treated with the strictest confidentiality.
MEDICAL QUESTIONNAIRE - DENTAL SURGERY
Name
Surname
Date of birth
Weight & Height
(w) (h)|
Postal Address
Country
Fax & Telephone numbers
(home)|||
(work)|^||
(mobile)|
(fax)||^^^|
E mail address
Occupation
Hobbies & Interests
Next of Kin
Tel.
Selected surgical procedure
Why are you considering this procedure?
Give details of the procedure you are requesting
Can you forward Xrays of your mouth?
Yes--- ||- No
Current Medication
Medical History
Allergies
Have you consulted a surgeon for this procedure? Give details
Do you smake or drink? Give details
Yes--- ||- No
Cigarettes / day
Drinks / day
Have you or your family ever had difficulties with Anesthetic?
Yes--- ||- No
Have you ever been ANEMIC?
Yes--- ||- No
Do you have ASTHMA?
Yes--- ||- No
Do you have LUNG DISEASE?
Yes--- ||- No
Do you have HIGH BLOOD PRESSURE?
Yes--- ||- No
Do you have any known HEART problems?
Yes--- ||- No
Have you ever been JAUNDICED?
Yes--- ||- No
Are you on the "PILL" or any other HORMONE?
Yes--- ||- No
Do you or any relatives with DIABETES?
Yes--- ||- No
Please name the surgeon
When would you consider travelling to South Africa?
