Hans Place Practice Registration Form

Hans Place Practice Registration

Please complete the form below
Full Name

First NameSurname
Date of Birth

DayMonthYear
Sex

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/CityCounty

Postcode
Occupation
1. Do you have any allergies?
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?
If yes, please explain
3. Do you suffer from heart arrhythmia or problems with heart rate?
If yes, please explain
4. Do you or members of your family have any blood coagulation (clotting) problems?
If yes, please explain
5. Do you bruise easily?
If yes, please explain
6. Do you suffer from regular nose bleeds?
If yes, please explain
7. Have you ever had a thrombosis (blood clot) - DVT/PE?
If yes, please explain
8. Are you pregnant or breastfeeding?
9. Do you have any medical disorder(s) of;
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)?
Please list all medications you're currently taking
13. Do you smoke or vape?
If yes, how many per day?
14. Do you drink alcohol?
If yes, how much per week?
15. Do you consent to Hans Place Practice to securely hold and store your medical records and data?
16. Would you like us to contact your GP about your appointment?
If yes, please provide your GP's name and address
17. Would you like a chaperone to be with you during your appointment?
How did you hear about Hans Place Practice?
Google, Word of mouth etc.
Signature
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