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Anaesthesia Ltd - Adult Preassessment Form
Please complete this form as early as possible to ensure there are no delays to your procedure.
* Required
Your name
*
Your answer
email
*
Your answer
Telephone number
*
Ideally a mobile, in case I need to contact you
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Have you ever been under my care?
*
Yes
No
Proposed operation
*
Your answer
Your insurance company
if you are claiming anaesthesia fees back
Your answer
Date of operation
*
MM
/
DD
/
YYYY
Your weight
*
in either kilograms or stones or pounds please
Your answer
Have you ever had a general anaesthetic?
*
This is where you would have been unconscious
Yes
No
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