Hans Place Practice Registration
Please complete the form below
Full Name
*
First Name
Surname
Date of Birth
*
Please select a day
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Day
Please select a month
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Month
Please select a year
2024
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Year
Sex
*
Male
Female
Other
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/City
County
Postcode
Occupation
1. Do you have any allergies?
*
Yes
No
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?
*
Yes
No
If yes, please explain
3. Do you suffer from heart arrhythmia or problems with heart rate?
*
Yes
No
If yes, please explain
4. Do you or members of your family have any blood coagulation (clotting) problems?
*
Yes
No
If yes, please explain
5. Do you bruise easily?
*
Yes
No
If yes, please explain
6. Do you suffer from regular nose bleeds?
*
Yes
No
If yes, please explain
7. Have you ever had a thrombosis (blood clot) - DVT/PE?
*
Yes
No
If yes, please explain
8. Are you pregnant or breastfeeding?
*
Yes
No
9. Do you have any medical disorder(s) of;
*
Liver
Kidneys
Intestines
Spine/Lower Back
Nervous System
None 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)?
*
Yes
No
Please list all medications you're currently taking
13. Do you smoke or vape?
*
Yes
No
If yes, how many per day?
14. Do you drink alcohol?
*
Yes
No
If yes, how much per week?
15. Do you consent to Hans Place Practice to securely hold and store your medical records and data?
*
Yes
No
16. Would you like us to contact your GP about your appointment?
*
Yes
No
If yes, please provide your GP's name and address
17. Would you like a chaperone to be with you during your appointment?
*
Yes
No
How did you hear about Hans Place Practice?
Google, Word of mouth etc.
Signature
*
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