Patient Registration Form

Name

First

Last

Date of Birth

Gender

Address

Email

Phone Number

Your Preferred Surgical Procedure or Treatment

Your Health History

Surgeries (if any): _________________________________________ Medications (current): _______________________________________ Allergies (if any): __________________________________________

Please check any conditions that apply to you:

Smoking:

Never
Socially
Current

If socially or current, please specify: _________________________

Alcohol:

Never
Socially
Regularly
Problematic

If regularly or problematic, please specify: ___________________

Drug:

Never
Socially
Current

If socially or current, please specify: _________________________

Would you like assistance for Travel and Accommodation planning?

Yes
No
Only traveling
Only accommodation

If socially or current, please specify: _________________________

This updated form includes a section dedicated to substance abuse and habits, enabling healthcare providers to gather essential information concerning the patient's lifestyle for more comprehensive treatment planning.

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