New Patient Registration

Please complete this form if you would like to arrange an appointment with Mr Draper.

Include as many details as you feel able, but note there are some compulsory fields marked with *.

Whether or not you decide to proceed with surgery, completing this form will stream line your work up for surgery. It will help us to arrange the earliest possible surgery date. If you would prefer to make an enquiry only, please click here.

Personal Details

Yes No
 

Medical History

Have you ever, or do you currently suffer from any of the following?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
 

Operations

Yes Ex Never

Medication (Please list all your current mediation, doses are not required)

 
 

Sleeping Patterns Do you tend to have any of these problems?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
 

 

Weight Profile

Yes No
Yes No

Which weight loss operation do you prefer at this stage?

 

Why do you want to lose weight with weight loss surgery?

(tick the box next to those that apply to you)

 

Fitness for Surgery

Yes No
Yes No

 

Personal Declaration

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