Minor Surgery Initial Questionnaire

Disclaimer

Please be advised, in order for the Dermatology Specialist to advise on treatment, you will be required to submit a clear photograph of the affected area for review.

General Information

Patient first name *

Patient surname *

Date of birth *

Email Address *

Mobile / Phone number *

Gender at Birth *

MaleFemale

We request for patients to confirm their gender assigned at birth as sex hormones can significantly influence treatment outcomes.

Address *

Street address *Street address line 2

City *

Postcode *

Health Information

Do you have any existing medical conditions? *

YesNoUnsure

Please list any and all your medical conditions *

Have you previously had any surgical procedures *

YesNoUnsure

Please provide further information *

Have you ever had keloid scarring? *

YesNoUnsure

Have you ever had local anaesthesia (lidocaine)? *

YesNoUnsure

Are you taking any prescribed medications? *

YesNo

Please list your current prescribed medications, including dose *

Are you taking any supplements, herbal treatment, alternative treatment? *

YesNo

Please any supplements, herbal treatment, alternative treatment you are currently taking *

Do you have any allergies? *

YesNo

Please list any allergies *

Do you have any other known intolerances? i.e . pollen, plaster, food *

YesNo

Please list any know intolerances *

Please provide any further details of your current and past medical history

Treatment

What treatment are you interested in? *

Please upload clear and sharp photos of concerned areas *

Browse

How long have you had this concern? *

Have there been any recent changes to the area? *

Which clinic do you wish to visit? *

Market HarboroughLeicester

Contact

How did you hear about us? *

How do you wish to be contacted? *

Phone CallSMSWhatsAppEmail

Consent

I consent to being contacted by RPM Health in relation to the information provided on this form *

By submitting this form, you are declaring that all the information provided is true and complete to the best of your knowledge. You confirm that you have not omitted any details that could affect your ability to receive treatment or safely use the product. You understand that providing inaccurate or incomplete information may impact the safety and effectiveness of your treatment. *

Your personal and medical information is collected and stored securely in accordance with the UK General Data Protection Regulation (GDPR) 2018 and the Data Protection Act 2018.This information is used solely for the purposes of providing safe and effective medical care, managing your treatment, and fulfilling legal or regulatory obligations.