surgeo-and-safari

 

 

 

STEP BY STEP GUIDE

CLIENT COMMENTS

PUBLICITY

 

"Once I saw the hospital and met them, all doubts departed."

Susan

Informed Choice - Questions you need to ask yourself

  • Are you able to use extended forms of communication like Email, Telephone and communicate with Past clients?
  • Have you asked questions, raised your concerns and fears?
  • How do you feel about how the Surgeon has addressed your questions?
  • Has your communication been open and honest?
  • Are you sure that you have realistic expectations?
  • Have you been made aware of the benefits and risks involved?

 

Name
Surname
Date of Birth
Weight and Height
W
H
Postal Address
Country
Telephone
Fax
Email Address
Occupation
Sport and hobbies
Selected Surgical Procedure
Why are you considering this procedure?
Give details of the procedure you are requesting?
Current Medication
Medical History
Do you have any recent medical records
Yes No
If so, please give Doctor's name
Contact telephone no for this Doctor
Allergies
Have you consulted a surgeon for this procedure? Give details
Are currently consulting a Physiologist or Physiatrist
Yes No
If so, have you consulted in view of your intention to have the above mentioned surgery
Yes No
Do you drink or smoke? Give Details
Yes No
Cigarettes / Day
Drinks / Day
Have you or your family ever had difficulties with General Anaesthetic?
Yes No
Are you prone to KELIODS or poor scaring?
Yes No
Have you ever been ANAEMIC?
Yes No
Do you have ASTHMA or LUNG DISEASE?
ASTHMA Yes No
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 have DIABETES?
Yes No
Do you take Warfarin, Aspirin or Arnica
Joint Affected
Underlying diagnosis of joint pathology
Give details Osteoarthritis and Rheumatoid
Can you forward X-rays ?
Yes No
Family history of thrombosis
Please name the surgeon
When would you consider travelling to South Africa?
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW

I have read the terms and conditions above:
Yes No
After sending this form we require you to email or post past medical records and X-rays to:

Surgeon and Safari
PO Box 97646, Petervale, 2151, South Africa

Please click on the send button or print this page
and then fax to : +27 11 706 5582
Enter Text Shown in Picture Below:

Please be assured that all electronic data received is treated with the strictest confidentiality.

Any medical or surgical advice provided through this web site service, even if intended to be accurate to the best of our knowledge, should be discussed with the surgeon before embarking on any treatment, medication or therapy.

Thank you for taking the time to complete this profile.



 

Last Update: