Surgical e-Consult Form

Our e-Consult service has been designed for our International Patients and those who are unable to physically present themselves to our clinic in Marbella for a Comprehensive Examination, Diagnosis and Discussion.




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Home > Surgical e-Consult Form

Surgical E-Consult Form Instructions

All information associated with your e-consult submission will remain strictly confidential and will not be distributed or published unless you provide us with written consent for release of such information.

Please fill out the e-consult Registration form and provide us with the any of the items listed below:

• A detailed and accurate description of the proposed treatment.
• A Scanned x-ray or photographs, Film x-rays should be scanned at a minimum of 300dpi, digital x-rays can be e-mailed to you from your doctors office or Radiologist and then attached to this e-consult request.
• An accurate description of your health with a complete list of medications (dosage and regimen) you are currently taking or have taken recently.

Basic Patient Info:

Patient Name:

Date Of Birth (DD/MM/YY):

Address 1:		Telephone No:
Address 2 / Town:		Mobile Tel:
Postcode:		Email:
County/State:		Nationality:
Country:		Passport / DNI:

Place of Referral:

How Did You Hear About Marbella Medical:

Emergency Contact:

Emergency Contact Name:

Relationship With Contact:

Contact Address:

Emergency Contact Telephone:

Nationality:

History Of Past Childhood Illness - Have You Ever Had:

Measles

Mumps

Chicken Pox

Congenital Abnormalities

Rhumatic Fever

History Of Past Adult Illness - Have You Ever Had:

Asthma

High Blood Pressure

Cancer

Diabetes Type I or II

Ulcer of Gastritis

Thyroid Problems

Tuberculosis

Kidney Problem

Liver Problems

Blood Problems

Venereal Disease

Heart Failure

Heart Attack

Abnormal Heart Rhythm

Have You Ever Had Any Serious Illness

Have You Ever Had A Transfusion

Have You Ever Been Hospitalised or Been Under Intensive Care

If Yes, Please Explain The Reasons:

Most Recent Immunizations:

Hepatitis B

Flu Vaccine

Pneumovax

Tetanus

Past Operations / Medical Care:

Have You Ever Had Any Surgery

If Yes, What Type Of Surgery?

Injuries:

Have You Ever Been Seriously Injured In A Motor Vehicle Accident

Have You Ever Suffered From Concussion

Have You Ever Been Knocked Unconscious

Allergies & Medications - Does Your Body React To:

	General / Local Anesthetics		Penicillin		Sticking Plasters		Other Medications
Other Kind Of Medication Are You Taking?

Social History:

How Many Units Of Alcohol Do You Consume A Week?

Are You

With Whom Do You Live With

Do You Use Recreational Drugs?

Foreign Travel Within The Past Year

Do You Smoke or Use Tobacco?

Are You Employed

If Yes, What Is Your Job?

Have You Ever Been Exposed To Dust, Fumes or Solvents?

How Much Time Have You Lost From Work Due To Illness?

Education

Do You Wear Seatbelts

Patient Weight Information:

What Is Your Approximate Weight?

Have You Had A Recent Weight Change?

Have You Generally Been In Good Health All Your Life?

Do You Suffer From / Or Recently Had Any Of The Following:

Skin:

Skin Disease

Jaundice

Eczema

Head, Ears, Nose & Throat:

Dry Eyes Or Mouth

Bleeding Gums

Blurred Vision

Sneezing Or Runny Nose

Nosebleeds (Frequent)

Chronic Sinus trouble

Ear Disease

Frequent Or Severe Headaches

Gastrointestinal:

Vomiting Blood Or Food

Gallbladder Disease

Change In Appetite

Hepatitis

Painful Bowel Movements

Endocrine:

Hormone Therapy

Change In Hat Or Glove Size

Change In Hair Growth

Become Colder Than Before Or Skin Has Become Drier

Hematologic:

Are You A Slow Healer After Cuts

Anemic

Phlebitis Or Blood Clots In The Veins

Have You Had Difficulty With Bleeding After Any Kind OF Surgery

Do You Have Abnormal Brusing Or Bleeding?

Respiratory:

Asthma Or Wheezing

Difficulty Breathing

Any Kind Of Lung Trouble

Pleurisy Or Pneumonia

Cough Up Blood

Cardiovascular:

Chest Pain, Pressure Or Tightness

Shortness Of Breath When Walking or Lying Down

Difficulty Walking More Than 100m

Palpitations

Swelling Of Hands, Feet Or Ankles

Difficulty Breathing When Asleep

Heart Murmor

Gentourinary:

Loss Of Urine

Blood In Urine

Frequent Urination

Kidney Trouble

Prostate Problem

Sexual Dysfunction

STD / Aids Risk

Gynecological (Women Only):

Date Of Beginning Of Last Period

Age Periods Started

How Long Do Your Periods Last?

Do You Feel Discomfort During Your Periods

Number Of Pregnancies

Number Of Miscarriages

Neuro-Psychiatric:

Transient Blindness

Tremor

Numbness In Fingers

Councelling For Mental Health Problems

Been Advised To See A Psychiatrist

Do You Ever Have Fainting Spells

Reason For Cosultation:

Please describe the treatment you wish to have as best as you can. Please Give Your Reasons for requesting a consultation (proposed Cosmetic Surgery treatment/existing condition/second opinion/etc):

Do you have any other medical conditions we should know about or be aware of that could effect your treatment? Have you ever had serious problems associated with Anaesthesia? Please explain:

Please attach any Image files such as x-rays, treatment plan(s) or contracts and clinical chart notes. (Please note images must be in JPEG format)

X-Ray Image:

X-Ray Image 2:

Picture 1:

Picture 2:

Picture 3:

Picture 4:

Please Allow Upto 5 Minutes For This Form To Send, Depending On The Number Of Pictures Attached.
Submission Date/Time:

Registered Business Address: Edif.65 5º Rincón del Mar, Avda. Ricardo Soriano 65, Marbella 29600, Andalucia, España
Uk Freefone: 0800 949 6750 | Mainland Europe Tel / Fax: +34 951 968 666 | Email: info@marbellamedical.com


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