Pre Consultation Questionnaire

1Contact information

2Medical accounts

3GP info

4General info

5Medical background

6Declaration

Title*
Surname*
First Name*
Address*
Address City State PostCode
Mobile number*
Home number
Email address*
Email address Confirm email
Date of birth*
YYYY dash MM dash DD
Gender*
- Male
- Female
Occupation*
Emergency contact*
Relationship*
Important information
Norwest Plastic Surgery may, on occasion, wish to communicate with you by email. All email communications are performed with particular regard to the privacy and confidentiality of your health information, however email communication are NOT ENCRYPTED, and therefore carry a higher risk. Email does not replace other forms of communication with your practitioner, such as consultation visits. Consenting to communicate with us by email assumes the following: - You acknowledge that the privacy and confidentiality of your health information may be compromised when communicating by email without encryption. - Only non urgent matters shall be communicated by email, as practice staff may not read all their emails on a daily basis. Urgent matters will always be communicated by telephone.
If you hare happy to receive email communications from us you will need to provide your written consent below:*
- I CONSENT to email communication with and from Norwest Plastic Surgery.
- I DO NOT CONSENT to email communication with or from Norwest Plastic Surgery.