Booking ID Full Name Date of Birth Postal Address Email Telephone Surgery Surgery Package Price Do you require transfers to and from the airport? Yes No Arrival Date & Time Departure Date & Time Airline & Flight No Do you require one nights stay in a hotel? Yes No If yes, will you require transfers to the hotel? Yes No If you have made your own hotel arrangements do you require transfers to this hotel? Yes No Name of your Hotel Where did you hear about us? Current weight Height BMI if known Goal Weight Allergies Medical Conditions (heart disease, high blood pressure, diabetes etc.) Previous Surgeries (including dates, details of surgeries, and if necessary any reports or documentation regarding this surgery) Medications (including dosages and reasons for taking this medication) Have you had covid? Yes No Do you have long covid? Yes No Have you had covid vaccinations? Yes No If yes which brand and how many vaccinations If you are female, how many pregnancies to term have you had? If you are female, how many pregnancies to term have you had? Aspirin Ibuprofen (Advil, Motrin) Aleve Coumadin Prednisone Methotrexate Humira Do you have any blood or blood clotting disorders? Do you smoke cigarettes on a daily basis? Do you drink more than 2oz of alcohol/day? Yes No Do you have any trouble swallowing pills? Yes No Have you had outbreaks of oral herpes in the past (cold sores around the mouth)? Yes No Are you HIV positive? Yes No Are you Hepatitis B positive? Yes No Are you Hepatitis C positive? Yes No Have you ever had MRSA (Methicillin Resistant Staphylococcal infection)? Yes No If yes to any immune disorders, what is your current status (virus free, cured, taking medication)? Have you had any problems with anaesthesia in the past? Can you take morphine? Yes No Dont Know Can you take demerol? Yes No Dont Know Can you take epinephrine? Yes No Dont Know Do you have dry eyes? Yes No Do you have lens implants in your eyes? Yes No Do you have sleep apnea? Yes No Do you have sleep apnea? If yes, do you wear CPAP at night? Have you ever had a blood clot? Yes No Have you ever had a blood clot(s) that went to your lungs (pulmonary embolus)? Yes No Send
