Patient Medical & Bariatric Surgery Inquiry Form

Patient Medical & Bariatric Surgery Inquiry Form

Please fill in this form with as much detail as possible. It will be sent to Dr Hruby who will assess it and we will then get back to you if we need more information or if we need to speak with you personally. If he has sufficient information he will approve you and we will send you a quote and a date and ask if you would like to go ahead for surgery. It usually takes up to 5 working days for us to get back to you. If you do not hear from us please contact me on info@newleafwls.co.uk or ring Amanda on 07551958653
Personal Details
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Gender

Other
Email Address
example@example.com
Contact Phone Number including country code
Please enter a valid phone number.Format: (044) 7551958653.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
Medical Questions
Height (cm)
Weight (kg)
BMI
Preferred Procedure

Other
Do you have any of the following conditions?
Please list any current medications
Please list any allergies
Have you had any previous surgery?
If yes, please specify the type and year of previous surgery and any complications if any
Have you previously had bariatric (weight loss) surgery?
If yes, please specify the type and year of previous bariatric surgery and any complications of problems if you are applying for revision surgery
Lifestyle information
Do you smoke?
Do you drink alcohol?
How many units per week
How often do you exercise?
Lifestyle information (check all that apply)
Date of surgery

Patients arrive on a Monday for consultations and tests. Surgery is usually Tuesday or Wednesday. Please provide 3 preferred Mondays you would like and we will do our best to accommodate you.
Preferred Surgery Dates (Option 1)

DayMonthYear
Date
Preferred Surgery Dates (Option 2)

DayMonthYear
Date
Preferred Surgery Dates (Option 3)

DayMonthYear
Date
Next of Kin Details
Next of Kin Full Name

First NameLast Name
Relationship to You
Next of Kin Phone Number with country code
Please enter a valid phone number.Format: (044) 7551958653.
Cross Border Directive

Patients from other EU countries can claim the cost of their surgery back through the Cross Border Directive scheme.We can help facilitate this for you. There will be a non refundable consultation charge of 200 euro for our support in helping you apply for this directive which includes assistance with submitting forms, receipts etc. Although the majority of claims submitted have been successful we cannot guarantee any outcome or that you will receive any or all monies reimbursed:
Will you be applying for CBD refund
All prices are for a shared room with one other person and a shared bathroom. Would you prefer a private room at an additional cost of ¢300
Please upload a full length photo of you fully clothed if you cannot upload, please email to info@newleafwls.co.uk *

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Patient Medical & Bariatric Surgery Inquiry Form

Personal Details

Medical Questions

Lifestyle information

Date of surgery

Next of Kin Details

Cross Border Directive