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Call us on +44 (0)333 050 2492 or fill in the form below

Call us on +44 (0)333 050 2492
or fill in the form

Name(Required)

Age(Required)

Please enter a number from 18 to 100.

Weight(Required)

Please enter a number from 40 to 200.

in kg

Height(Required)

Please enter a number from 120 to 240.

in cm

Date(Required)

MM slash DD slash YYYY

Allergies

Current Medications

Prescription and Non-Prescription (include all over-the-counter medications; herbal supplements; complementary or alternative medicines)

Prior Operations

Your responses to the following questions will help us determine and provide the anesthetic that is best for you.

Have you recently had a cold or the flu?(Required)

Yes

No

Are you allergic to latex (rubber) products?(Required)

Yes

No

Have you experienced chest pain?(Required)

Yes

No

Do you have a heart condition?(Required)

Yes

No

Do you have hypertension (high blood pressure)?(Required)

Yes

No

Do you experience shortness of breath?(Required)

Yes

No

Do you have asthma, bronchitis, or any other breathing problem?(Required)

Yes

No

Do you (or did you) smoke?(Required)

Yes

No

Packs/day(Required)

Number of years(Required)

Date you quit

MM slash DD slash YYYY

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