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.
Have you ever, or do you currently suffer from any of the following?
(tick the box next to those that apply to you)