Online Preliminary Consultation Form

The Online Preliminary Consultation is a service offered to patients located outside the United Kingdom. It is designed to provide potential patients with general feedback and information in order to better decide whether to seek care in our office.

Please take time to fill out all questions on the form carefully and completely.

Dr Sorensen will review the submissions and determine whether you appear to be a suitable candidate for treatment. Your submissions will be followed up by a phone call from our staff within one working week.

Please take special care in ensuring that photos you submit are of good quality and are made in accordance with the photo quality/size guidelines.

[Photo Guidelines]

Title

First Name

Last Name

Address

Postcode

Country

Telephone

Best time to call

Profession

Date of birth

Weight

Height

Smoking

Do you have any known allergies?

If yes, please specify

Do you take Aspirin, Ibuprofen, Nurofen, Fish Oil, Flax Oil, Omega Oil or Vitamin E?

Medications taken

Alternative medicines

(incl. herbal and homeopathic medicines)

Do you have any general health problems or conditions?

If yes, please describe

Have you had any previous surgery?

If yes, please list procedures, approximate dates and outcomes

Do you usually heal well after suffering minor wounds?

If no, please describe

you usually have prolonged bleeding after suffering minor wounds?

What type of surgery are you considering

Please describe as specifically as possible the nature of your concern and desire for surgery

Please describe your expectations from surgery

Do you have any particular concerns regarding the surgery?

If yes, please specify

Have you already seen another doctor regarding this surgery?

If yes, please note their recommendations

Do you have an approximate time period in mind for your visit?

If yes, please specify

Will you be traveling allone?

Where will you be residing during your stay?

Do you have any special requirements we should know about?

If yes, please explain

Is there any other information you wish to share with us now?

If yes, please explain

Do you understand and accept in full the Conditions and Terms of Use for the Online Preliminary Consultation programme?

Type your full name to attest that the enclosed information is accurate and complete

Attaching Photos

You may attach up to 5 photos from your computer. Please review our guidelines and the photo quality/size requirements before attaching your files.

Attach image *

Attach image

*Required to attach minimum one photo

Note: If for any reason you are unable to attach images to the form, you may email them separately along with a brief message clearly identifying yourself and the images.

Submitting your form

If you wish to save a copy of this form, please print now before submitting.