Time Reversal



	We are a health tourism organisation specialising in trips to South Africa for excellent General Surgery, superlative Cosmetic Surgery and Cosmetic and Reconstructive Dental Surgery. And Specialised In-patient Treatment for Drink & Drug Addictions, Eating Disorders and Depression. We also organise comfortable recuperation and exciting post-treatment holidays.

The practice of surgery is not an exact science and, although good and even excellent results are expected, there cannot be any guarantee or warranty, expressed or implied, by anyone, as to the result that will be obtained. Complications do occur in surgical practice, despite every effort to prevent them and those relevant to the operations you may elect to undergo will be discussed with you during your consultation.

Please complete this form and submit it online. Alternatively you can print it out and fax it to us on:
F: 020 7235 9583, or email it to us at: lesley@timereversal.co.uk

Patients Medical Questionnaire

*Denotes Required Fields

FIRST NAME*:
SURNAME*:
ADDRESS*:
TELEPHONE*:
AGE:
HEIGHT:
WEIGHT
IS YOUR WEIGHT STABLE?	Yes: No:
WHAT MEDICATIONS ARE YOU TAKING ON A REGULAR BASIS (INCLUDING ASPRIN):
ANY KNOWN ALLERGIES:
ARE YOU A SMOKER:	Yes: No:
IF YOU STOPPED SMOKING THEN HOW LONG AGO DID YOU STOP:
DO YOU HAVE ANY HEART OR CHEST PROBLEMS:
IS YOUR BLOOD PRESSURE NORMAL:
WHEN WAS YOUR LAST GENERAL ANAESTHETIC:
ON WHAT SURGICAL PROCEDURES WOULD YOU LIKE INFORMATION