Eton Medical Patient Form

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First Name

Last Name

Date of Birth

Phone

Preferred Date/Month for your treatment

Sex

Height?

Weight

Do you currently have any planned hospital treatments/surgeries?

Do you have any previous surgical history?

Do you have any implants (dental, orthopaedic or cosmetic)

Do you have any of the following conditions?

Other conditions not listed above

Have you experienced issues with sedation/anaesthesia?

Do you have difficulty with healing or scarring?

Do you smoke? If so, how many cigarettes do you have per day?

Do you drink alcohol? If so, how often?

Are you taking any medications? If so, please provide the list below.

Are you taking any blood thinners or anti-coagulants (daily aspirin, heparin, warfarin/coumadin)?

Have you ever taken an MAO inhibitor such as Nardil, Marplan or Parnate?

Are you taking any vitamins or other nutritional supplements on a regular basis?

Do you have any allergies or intolerances? If so, please provide the details below.

Do you have any other medical condition, injury or anything else we should be aware of that may be relevant to your medical request?

Anything else you'd like us to know or ask the surgeon?

Please upload photos here such as medical reports and photos

Click or drag files to this area to upload.

You can upload up to 50 files.

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By continuing, you agree to the Terms. Read the Privacy policy and I agree that my given details including health data may be processed by Eton Medical for the purpose of obtaining quotes. This includes the transfer of my data to healthcare providers within and outside the EU. The consent can be revoked at any time with effect for the future.

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