PERSONAL HEALTH PROFILE

Desired Surgery

What kind of surgical procedure(s) you are interested in?

What are the results you wish to achieve?

Your Health

Do you have any medical conditions?

Are you taking any medication or herbal preparations? State name and dosage

Have you had any cosmetic surgery before? Please state year and procedures

Are you anemic or have a history of jaundice, hepatitis or HIV? If yes, please provide details.

Do you have any of the following conditions?

High Blood Pressure/ Hypertension
Diabetes
Any bleeding problems
Any Skin problems
Allergies to medication
Food allergies
Do you take aspirin or blood thinners
Any reaction to local or general anaesthesia
Other medical problems, including communicable diseases? If Yes, please describe:

Is there anything your surgeon should be aware of for the management of your treatment and/or to make your stay at the hospital more comfortable?

I understand that all the information furnished above is accurate and true.

We comply with the General Data Protection Regulation (GDPR) at FlytoCure Healthcare Ltd. The main aim in the GDPR is to unify and simplify the regulator environment and to strengthen the data protection of individuals. Patients who have their operations carried out will have their data shared with regulator bodies for clinical governance. The bodies involved are: (a) PHIN Private Healthcare Information Network. (b) CQC Care Quality Commission. (c) National breast implant registry, if applicable. (d) Healthcare provider, where operations are performed. (e) Data will be kept at FlytoCure Ltd for at least 8 years, hard copies in a secured way. (e) Part of the data will be kept electronically in a secured way for audit purposes and Clinical Governance. (f) Information will be shared with other Health Professionals, including their GPs and NHS services for various Investigative procedures, Haematology or Microbiological Screening etc.

I consent the use of my information anonymously for medical audits and medical articles.