Please list all current medications
Field is required!
Field is required!
Do you take any blood thinning agents? (eg. Asprin, Asasantin, Plavix, Warfarin, Pradaxa, Xarelto, etc)
Field is required!
Field is required!
Do you have any allergies? If yes, please provide details.
Field is required!
Field is required!
Do you smoke cigarattes? If yes, how many and for how long?
Field is required!
Field is required!
Please list previous surgical procedures and dates (DD/MM/YYYY)
Field is required!
Field is required!
Other relevant information
Field is required!
Field is required!
How did you hear about Mr Russell? (GP, Specialist, Google, Our Website, Personal Recommendation/Friend, Other)
Field is required!
Field is required!
