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 detailsMetals (Eg: Skin Contact)* Yes No If Yes, please specify type and reaction detailsOthers (Food/Medication)* Yes No If Yes, please specify allergen and reaction detailsDIABETIC* Yes No INSULIN DEPENDENT* Yes No HAVE YOU SUFFERED FROM BLOOD CLOTS:* Yes No If Yes, detailsMedicationsAre you currently taking BLOOD THINNING medication:* Yes No If YES which medications are you taking?Warfarin* Yes No Clopidogrel - Plavix* Yes No Rivaroxaban - Xarelto* Yes No Aspirin* Yes No Pradaxa – Dabigatran* Yes No Eliquis – Apixaban* Yes No Other (Please specify)Are you currently taking RHEUMATOID ARTHRITIS medication:* Yes No If YES which medications are you taking?Methotrexate* Yes No Prednisolone* Yes No Other (Please specify)Are you currently taking a WEIGHT LOSS/DIABETIC INJECTION medication:* Yes No If YES which medications are you taking?Ozempic* Yes No Semaglutide* Yes No Other (Please specify)Are you currently taking ANTI-INFLAMMATORY medication:* Yes No If YES, please specifyAre you currently taking any OTHER medications: Yes No If YES, please specifyNameThis field is for validation purposes and should be left unchanged.
