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Dental Surgery Medical Form

Thank you for visiting the Surgery and Holiday web site.
Surgery and Holiday will forward your medical details to your selected surgeon who will reply with his basic clinical evaluation and any relevant details as soon as possible.

Please Note: For this enquiry to reach us you must provide a valid email address.
Name
First Name
Date of Birth
Weight and Height
W
H
Postal Address
Country
Phone number
Fax
Mail
Occupation
Hobbies and Interests and sport
Selected Surgical Procedure
Why are you considering this procedure ?
Give details of the procedure you are requesting ?

Can you forward Xrays of your mouth ? Yes   No
Current Medication
Medical History
Allergies
Have you consulted a surgeon for this procedure ? Give details
Do you drink or smoke ? Give Details Yes   No
 
Cigarettes / Day
Drinks / Day
Have you or your family ever had difficulties with General Anaesthetic ? Yes   No
Have you ever been ANAEMIC ? Yes   No
Do you have ASTHMA or ASTHMA Yes   No
           LUNG DISEASE ? LUNG DISEASE Yes   No
Do you have HIGH BLOOD PRESSURE ? Yes   No
Do you have any known HEART problems ? Yes   No
Have you ever been JAUNDICED ? Yes   No
Are you on the "PILL" or any other HORMONE ? Yes   No
Do you or any relatives have DIABETES ? Yes   No
   
Please name the surgeon you have selected
When would you consider travelling to Tunisia ?
   
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I have read the terms and conditions above
   
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