Hans Place Practice Registration Form

Hans Place Practice Registration

Please complete the form below
Full Name*

First NameSurname
Date of Birth*

DayMonthYear
Sex*

MaleFemaleOther
Preferred Pronoun
E.g. He/Him, She/Her, They/Them
E-mail*
Primary Contact Number*
Incl. dial code
Contact Number 2
Incl. dial code
Address*

Street Address

Street Address Line 2

Town/CityCounty

Postcode
Occupation
1. Do you have any allergies?*

YesNo
If yes, please explain
2. Do you have or have had any disorders of the heart and/or circulation? Such as high or low blood pressure, angina or cardiac arrest?*

YesNo
If yes, please explain
3. Do you suffer from heart arrhythmia or problems with heart rate?*

YesNo
If yes, please explain
4. Do you or members of your family have any blood coagulation (clotting) problems?*

YesNo
If yes, please explain
5. Do you bruise easily?*

YesNo
If yes, please explain
6. Do you suffer from regular nose bleeds?*

YesNo
If yes, please explain
7. Have you ever had a thrombosis (blood clot) - DVT/PE?*

YesNo
If yes, please explain
8. Are you pregnant or breastfeeding?*

YesNo
9. Do you have any medical disorder(s) of;*

LiverKidneysIntestinesSpine/Lower BackNervous SystemNone of the above
10. If you have any other medical problems not listed above, please explain
11. Please list any operations you've previously had (incl. Cosmetic)*
Please provide dates if possible
12. Are you currently taking any regular medication (incl. contraceptive pill & HRT)?*

YesNo
Please list all medications you're currently taking
13. Do you smoke or vape?*

YesNo
If yes, how many per day?
14. Do you drink alcohol?*

YesNo
If yes, how much per week?
15. Do you consent to Hans Place Practice to securely hold and store your medical records and data?*

YesNo
16. Would you like us to contact your GP about your appointment?*

YesNo
If yes, please provide your GP's name and address
17. Would you like a chaperone to be with you during your appointment?*

YesNo
How did you hear about Hans Place Practice?
Google, Word of mouth etc.
Signature*

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