Surgery reservation form

PREMIER CLINIC

Company: PC Healthcare s.r.o.

VAT ID: 19822634

Jungmannova 26/15, Prague 1

booking@premier-clinic.cz

www.premier-clinic.cz

UK: +44 208 157 6867

Whatsapp: +420722536103

Patient's Full Name*

First NameLast Name

Date of Birth *

Date

Type of procedure:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail Address*

Nationality:*

Do you have other requirements that you want to tell us?

Requested day of surgery (Please enter the day of the operation that was offered to you by the coordinator)*

Date

Do you want to arrange accommodation?

Yes, I want to arrange accommodationNo, I don't want to provide accommodation

If you want to book a hotel, please specify:

Apartment (78 EUR / night)Salvator Boutique hotel Prague (85 EUR / night)

I will arrange for a pre-operative examination and laboratory:

In the clinic (180 EUR)I will supply the pre-operative one 14 days before the operation from my doctor (please request the documents of which values we need)

Sonography: (necessary for breast surgery)

In the clinic (80 €)I will supply sonography from my doctor.

Accompanying Information:

I travel aloneI am traveling with a companion

If you are traveling with a companion - specify the number of people:

Height

Weight

Please give information about patients health.*

	NO	YES	If YES please specify.
Are you allergic? If yes, please indicate
Are you allergic to anaesthetics?
Do you have high blood pressure?
Is anyone in your family allergic to anaesthetics?
Have you ever had difficulty during/after anesthesia?
Do you smoke? YES - NO. If YES, how many cigarettes?
Diabetes?
Do you suffer from asthma or any other respiratory disease?
Do you have thyroid gland disease?
Do you have a cancer (family history)?
Do you have cardiovascular disease (hypertension, angina, myocardial infarction,...)
Do you have chronic inflammation or other kidney disease?
Do you have stomach or duodenal ulcers or a hernia in the navel/abdominal wall?
Are you vaccinated against COVID-19? If YES, your last dose was on - please specify.
Do you suffer from heavy bleeding when injured?
When was the last time you were examined by an internal medicine physician? - please specify
Have you had any surgeries? If YES, when and what kind? Please specify
Do you have an infectious disease (TB, HIV, hepatitis, AIDS or other infectious disease....)
Do you have an immune disorder?
Do you have epilepsy?
Do you have mental health problems?
Do you have migraines?
Do you have seizures/spasms?
Do you have rheumatism?
Do you have liver and kidney disease?
Do you have stomach and intestinal disease?
Please list all medications you take including herbal, natural supplements, skin medications...) and why?
If you are allergic to any medications, please indicate which ones.
Do you take: Anticoagulants (blood thinners)? if YES, please indicate which ones.
Contraceptives?
Antibiotics?
Cortisone?
NO NSAID (non-steroidal anti-inflammatory drugs)?
Herpes?
Active acne?
Are you pregnant?
Are you breastfeeding?
Egularity of menstrual cycle?
Menopause?
Have you had surgery (including plastic surgery) or tooth extraction in the last 6 months? If YES, please specify at which clinic or the doctor’s name?
Has your body weight changed in the last 6 months?
Are you currently under medical supervision? If YES, for what reason?
Have you ever been hospitalized? If YES, please indicate the reason, year of hospitalization, year of diagnosis
What is your occupation (sedentary, physical, mental, light, heavy, etc.)?

If you want to upload any documents you can upload it here.

I declare that I have fully understood all the above questions and have answered them truthfully and completely. I have had the opportunity to ask any questions on the matter, all questions asked by me have been answered. I understand the need to have pre-operative tests (blood tests, ECG and possibly others as required by the clinic) and understand that without their submission the requested procedure cannot be performed. By signing this document, the client agrees to the collection, storage, and processing of personal data (including sensitive data) by the clinic, solely for the purpose of performing the procedure or maintaining medical records of the procedure, where the clinic will be the service provider and the data subject (client) will be the recipient.

The client declares that he/she has been informed of his/her rights under the relevant legislation. This means, in particular, that the provision of personal data to the clinic, as the controller for the above purpose, is voluntary, that he/she has the right to access them, has the right to revoke the aforementioned consent at any time at the address of the clinic and has the right to contact the Office for Personal Data Protection in case of violation of his/her rights and to request appropriate remedy. This remedy includes, for example, refraining from the clinic's actions, remedying the situation, providing an apology, making a correction or completion, blocking the disposal of personal data, paying monetary compensation, as well as exercising other rights under the relevant legislation.

The clinic declares that it will collect personal data to the extent necessary for the fulfilment of the stated purpose and will only process it in accordance with the purpose for which it was collected. Employees of the clinic or other natural persons who process personal data based on a contract with the clinic, and other persons who will have access to personal data based on this consent, are obliged to maintain confidentiality of personal data, even after termination of employment or work. Personal data is fully secured against misuse.

(In the event that a 3D simulation of breast augmentation is performed, the client acknowledges

that the 3D simulation in question does not give rise to a legal or aesthetic claim of the result of the operation and is only a simulation that is indicative.)

(The client agrees and acknowledges that an audio recording will be made of the consultation with the doctor, which will be archived by Premier Clinic Ltd.
/ BP Healthcare s.r.o. in accordance with Act No. 101/2000 Sb., on the Protection of Personal Data, and in accordance with Section 5(2) grants Premier Clinic s.r.o. / BP Healthcare s.r.o. consent to the collection of personal data for the purpose of archiving the audio-visual recording for future verification of the course of the consultation with the physician.)

(By my signature I confirm that all the information I have given in this questionnaire is true and that I have not concealed anything that could affect the procedure or treatment.)

Signed on:

Date

Signature

Reservation form

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