Pre-Operative Clinical Form Pre-Op Clinical Form Appointment cancellations after 9am the working day prior to your appointment (2 Business days for Psychology appointments) may incur a 50% cancellation fee.* indicates required fields Date* MM slash DD slash YYYY Surname* Given Name* Date of Birth* MM slash DD slash YYYY AllergiesAre you allergic to any of the following? Kefzol* Yes No If Yes, reaction details Metals (Eg: Skin Contact)* Yes No If Yes, please specify type and reaction details Others (Food/Medication)* Yes No If Yes, please specify allergen and reaction details DIABETIC* Yes No INSULIN DEPENDENT* Yes No HAVE YOU SUFFERED FROM BLOOD CLOTS:* Yes No If Yes, details MedicationsAre you currently taking any of the following medication:Warfarin* Yes No If Yes, specify dose Clopidogrel - Plavix* Yes No If Yes, specify dose Rivaroxaban - Xarelto* Yes No If Yes, specify dose Aspirin* Yes No If Yes, specify dose Methotrexate* Yes No If Yes, specify dose Prednisolone* Yes No If Yes, specify dose Pradaxa – Dabigatran* Yes No If Yes, specify dose Eliquis – Apixaban* Yes No If Yes, specify dose Ozempic (weight loss)* Yes No If Yes, specify dose Semaglutide* Yes No If Yes, specify dose Anti-inflammatories* Yes No If Yes, specify dose Other medications?CommentsThis field is for validation purposes and should be left unchanged.
