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Plastic surgery patient questionnaire
Plastic surgery patient questionnaire
"
*
" indicates required fields
1
2
3
1. Personal Information
Name:
*
First Name
Last Name
Birth date:
*
Day
Month
Year
Gender
*
Male
Female
Height (cm)
*
Weight (kg)
*
Hidden
KMI kg/m2
Phone
*
Please do not forget to add a regional/area code.
Email
*
Address
Street, House nr
City*
Province
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Emergency Contact
Name of Contact Person
*
Contact Person's Phone Number:
*
Please do not forget to add a regional/area code.
2. Surgery
What surgery do you desire?
*
Please describe your expectations regarding the surgery:
3. Health Information
Please indicate if you have or have had any of the following illnesses:
Hypertension
Coronary heart disease / Angina
Heart attack
Heart rhythm disorders
Heart valve disorder
Pacemaker
Heart failure
Other heart disease
Pulmonary embolism
Varicose veins / Phlebitis
Anemia
Asthma / Chronic bronchitis
Sleep apnea / Snoring
Other lung disease
Tuberculosis
Blood clotting disorders
Diabetes
Liver disease
Hepatitis A/B/C
Stomach and duodenal ulcer disease
High cholesterol or lipid levels
Kidney disease
Thyroid disorders
Stroke
Epilepsy / Seizures
Other neurological disease
Other muscular disease
HIV/AIDS
Tumors
Rheumatic diseases
Joint disease
Some other disease
None of the above
What year was the heart attack?
Please specify the answer "some other disease"
Do you experience prolonged bleeding from small wounds, frequent nosebleeds, or subcutaneous bruising?
*
No
Yes, one or more of these occur
Have you previously received blood transfusions?
*
No
Yes
Do you have any other health details to specify?
Medications, Allergies, Past Surgeries
List the medications you take regularly:
Enter the names and doses of your medications. If you do not take medications regularly, skip this section.
Medicine
Dose
Frequency of taking
Add
Remove
Do you have drug allergies?
No
Yes
Have you undergone surgeries in the past?
No
Yes
What medications are allergic to?
*
When and for what reason have you had surgery before?
Have you previously undergone general anesthesia?
*
No
Yes
When and for what reason have you previously undergone general anesthesia?
Other Important Information
Do you exercise regularly or engage in physical labor?
*
No
Yes
Do you experience shortness of breath at rest?
*
No
Yes
How many flights of stairs can you climb without resting?
What prevents movement on stairs?
Chest pain
Shortness of breath
Joint pain
Other
Movement is not restricted or hindered
Specify the answer "other"
Do you consume alcohol? How often?
Do you smoke? If yes, how much?
Do you use drugs? What kind and how often?
Do you have loose teeth or removable dentures?
No
Yes
Consent
*
1.Parties
1.1 The General Terms of Service of Bariatric Services AS regulate the mutual rights and obligations of the Service Provider and the Patient and the Service Provider when providing the Service.
1.2 In matters not regulated in the General Terms of Service, the Law of Obligations Act, the Health Services Organisation Act, other laws and the legislation adopted on the basis thereof shall apply.
2. Definitions
2.1 The Service Provider is a Health Care Professional or a legal entity providing Health Services (Bariatric Services AS).
2.2 For the purposes of the law, Health Services are the activities of Health Care Professionals for the prevention, diagnosis or treatment of diseases, injuries or intoxication in order to reduce the malaise of persons, prevent the deterioration of their state of health or development of the diseases, and restore their health. The Health Services offered by the Service Provider are listed on their website (available in Estonian: https://www.kaalukirurgia.ee/maovahendusoperatsioonid/).
2.3 Patient means a person who receives health services or who wishes to receive health services.
2.4 Health Care Professional means a health care professional employed by the Service Provider, i.e. a doctor or nurse registered with the Health Board.
2.5 The Patient and the Service Provider are deemed to have entered into a health services contract upon registration for the provision of the Health Service and payment of the invoice for the Service. By registering for the Health Service and paying the invoice, the Patient agrees to these General Terms of Services and undertakes to comply with them.
3. Entering into contract (making an appointment)
3.1 Patients can book a Service appointment by phone or email using the contact details on the Provider’s website (https://amselclinic.eu/en/contact/ ), or by using the enquiry form on the Provider’s website (https://amselclinic.eu/en/contact/).
3.2 When a patient books an appointment for Service, a health services contract is deemed to have been entered into between the Service Provider and the Patient.
3.3 The service is provided with the consent of the patient.
3.4 These General Terms of Service and any procedures, rules and requirements established by the Service Provider and made available to the Patient, which the Patient agrees to comply with when making an appointment for health services, constitute integral parts of the health services contract.
4. Rights and obligations of Parties
4.1 The Patient has the right to:
4.1.1. Obtain information about their medical condition and the Service from the surgeon, Bariatric Services AS and the Patient leaflet.
4.1.2. Cancel an appointment for the Service without giving a reason.
4.1.3. Demand that the Service Provider keep confidential the Patient’s health data and information about their treatment, provision of the Service and their private life (unless the Service Provider is legally required to disclose this information).
4.1.4. Confidentiality of their information held by the Service Provider. The Service Provider shall not disclose the Patient’s data to unauthorised persons, except in agreement with the Patient or if required by law.
4.1.5. Choose between different Services, refuse a Service.
4.1.6. Receive a high-quality Service that meets the general level of medical science. The Service Provider cannot promise the Patient’s improvement or the success of the surgery.
4.1.7. Submit proposals and complaints regarding the provision and organisation of the Service.
4.1.8. Actively participate in making decisions about their treatment and the Service, be involved in the treatment process, consent to or refuse the provision of the Service.
4.1.9. Receive instructions from the Service Provider on how to support, maintain and improve their health after the Service.
4.2. The Patient undertakes to:
4.2.1. Arrive on time for the Service or surgeon consultation at the agreed location.
4.2.2. Truthfully disclose to the Service Provider and the Health Care Professional any and all information concerning the Patient’s health that may be relevant to the provision of the Health Service to the Patient (including chronic diseases, previously performed bariatric surgery, etc.), as well as information that may affect the application of safeguards in the provision of the Health Service to protect the life and health of the Patient irrespective of whether the Service Provider requested the disclosure of such information.
4.2.3. Submit an identification document with a photo (ID-card, passport, driving licence).
4.2.4. Pay for the invoices provided by the Service Provider in due time.
4.2.5. Notify the Service Provider as soon as possible if they are unable to arrive at the booked time to receive the Service.
4.2.6. Provide the assistance needed by the Service Provider to provide this Service, which includes following the instructions given by the Service Provider during, before and after the provision of the Health Service.
4.2.7. Comply with the medically reasoned treatment and prescriptions assigned by a health care professional both during and after the provision of the Service.
4.2.8. Follow the Service Provider’s internal rules for Patients during their stay in the Hospital and any other requirements arising from legislation governing the conduct of Patients (laws, regulations, internal hospital procedures, etc.).
4.3. The Service Provider undertakes to:
4.3.1. notify the Patient about the results of their examination and the Patient’s medical condition, possible illnesses and their course, the nature and purpose of the Service provided, the risks and consequences of its provision and other possible and necessary Health Services. The Service Provider also undertakes to notify the Patient of the possibility to obtain information (including consultation) from the treating physician and the Service Provider before, during and after the provision of the Service.
4.3.2. Provide the Health Service to the Patient corresponding to the general level of medical science applicable during the provision of the Service and do so with care usually expected from the Service Provider.
4.3.3. Do everything reasonably possible for the benefit of the Patient when providing the Health Service, but the law prevents the Service Provider from making promises as to the medical success of the Health Service or the desired aesthetic outcome.
4.3.4. Document the provision of the Service in accordance with the applicable requirements and store such records.
4.3.5. Process the Patient’s personal data in accordance with the Estonian and European Union rules on the protection of personal data.
4.3.6. Explain to the Patient the follow-up care procedures to look after their health and the limitations to the Patient’s lifestyle associated with the provision of the Health Service.
4.3.7. Keep any data obtained about the Patient confidential from third parties according to legislation.
4.3.8. Analyse patient safety incidents that have occurred and been documented during the provision of the Health Service and develop measures to prevent such incidents. The Service Provider undertakes to notify the person maintaining the patient safety database of patient safety incidents in accordance with the Health Services Organisation Act.
4.4 The Service Provider has the right to:
4.4.1. Unilaterally change or cancel an appointment booked by the Patient for reasons related to the organisation of work or other material reasons. The Service Provider shall notify the Patient of any changes no later than within one working day.
4.4.2. Require the Patient to draw up a written consent to the provision of the Service.
4.4.3. Establish internal rules that govern the Patient’s conduct in the Hospital and require the patient to comply with such rules.
4.4.4. Refuse to provide the Service to the Patient (including booking an appointment) or terminate the provision of the Service if the Patient:
4.4.4.1. is late to receive the Service at the agreed time and place;
4.4.4.2. is intoxicated by alcohol and/or drugs;
4.4.4.3. has a debt to the Service Provider;
4.4.4.4. does not agree to sign an informed consent paper;
4.4.4.5. wishes to receive the Service without medical indication;
4.4.4.6. does not disclose the information necessary for the provision of the Service;
4.4.4.7. does not follow good communication practices;
4.4.5. Process the Patient’s personal data, including health data, necessary for the provision of the Service. To provide the Service, the Service Provider may need to access the Patient’s personal data in the Health Information System or via any storage media prior to the appointment. If the Patient cancels the appointment or fails to arrive after the Service Provider has examined their personal data for the purpose of providing the Service, access to the Patient’s personal data is deemed necessary for the provision of the Health Service.
5. Payment for services
5.1. The Patient undertakes to pay for the Service provided to them in accordance with the invoice submitted by the Service Provider.
5.2. Payment for the Service is generally made in advance no later than on the day of provision of the Service; detailed payment terms are set out on the invoice.
5.3. The Patient has the option to apply to credit institutions for payment by instalments. The Patient can ask the Service Provider for information on applying for payment by instalments.
5.4. The Patient is aware that the Estonian Health Insurance Fund does not reimburse the amounts payable for the Service.
6. Feedback and complaints
The Patient can provide feedback, suggestions and complaints to the Service Provider:
6.1. by e-mail at info@bariatricservices.eu
6.2. The complaints submitted by the Patient are registered and replied to by e-mail within 10 calendar days from the registration of the complaint.
7. Liability
7.1. The Service Provider provides the Health Service on the basis of treatment guidelines and the general level of medical science during the provision of the Health Service and with care usually expected from the Health Service Provider.
7.2. The Service Provider is not liable for the negative consequences of providing the Services if the Patient has been notified of the possible risks and consequences and the Patient has given consent to the provision of the Service.
7.3. The Service Provider will not be liable for any loss or damage if it is caused by the Patient’s breach of their obligation to provide information or assistance, including if the Patient fails to follow the Service Provider’s instructions when preparing for the Health Service or if the Patient provides false information about their health.
7.4. The Service Provider is liable for the wrongful breach of their obligations under the law, primarily for errors in diagnosing and treatment and a breach of the obligation to notify the Patient and obtain the Patient’s consent.
7.5. The Patient must prove the fact underpinning the Service Provider’s liability, unless the provision of the Health Service to the Patient is not properly recorded. The Patient’s claim for compensation for damage expires three years after the date on which they became aware of the breach of duty by the Service Provider and of the damage suffered in connection with the provision of the Health Service.
7.6. The Service Provider is supervised by the Health Board.
8. Patient’s consent
8.1. The Service Provider may examine the Patient and provide the Health Service to them with their consent. The Patient may withdraw their consent within a reasonable time after granting it.
8.2. At the request of the Service Provider, the Patient’s consent or the application for its withdrawal must be in a form reproducible in writing.
8.3. If the Patient (and/or their legal representative) decides to withdraw their consent immediately prior to the provision of the Health Service the full amount paid for the Health Service will be refunded to the Patient, with the exception of an advance payment of 500 EUR. The advance payment of 500 EUR relates to the preparation of the provision of the Health Service (including analyses, consultations) and is non-refundable. Information on refunds is stated on the invoice sent to the Patient and in the related terms and conditions.
8.4. If the Patient (and/or their legal representative) decides to withdraw consent during the provision of the Health Service, the Provider will discontinue the provision of the Health Service at the earliest opportunity if this can be done without harm to the Patient’s health, and the withdrawal of consent will be recorded in the records of the Health Service provision.
8.5. Non-universally recognised preventive, diagnostic or treatment methods may only be used if conventional methods promise less success, the Patient has been notified of the nature of the method and its possible consequences, and the Patient or their legal representative has consented to its use. A non-universally recognised method may be used on an incapacitated Patient without the consent of the Patient or their legal representative, if failure to use such a method would endanger the Patient’s life or cause significant harm to the Patient’s health.
9. Final provisions
9.1. The Service Provider has the right to unilaterally amend the General Terms of Service by publishing the changes on the website of the Service Provider. The General Terms of Service in force at the time of ordering the Service apply to the Patient.
9.2. In matters not provided for in the General Terms of Service and the Contract, if there is one, the Parties follow the current legislation of the Republic of Estonia. Disputes arising from the execution of this Contract will be settled by negotiation between the Parties. In the event of failure to reach an agreement, the disputes will be resolved in court pursuant to the procedure prescribed by the legislation of the Republic of Estonia. Harju District Court has jurisdiction over disputes arising from the Contract.
9.3. Alternatively, if the Patient has suffered avoidable loss or damage in the course of the provision of the Health Service, the Patient can apply for compensation to an insurer who provides insurance to the Service Provider, handles the case and decides on compensation. The Patient also has the option, after receiving a decision from the insurer of the Service Provider, to file a petition with the pre-trial liability insurance mediation committee of the Health Board to challenge the insurer’s decision if the Patient disagrees with it. Compensation for damage caused to the Patient in the course of the provision of the Health Service, and the procedure for settling liability insurance disputes (including the procedure of the liability insurance mediation committee) are regulated by the Act on Compulsory Liability Insurance of Health Care Providers.
9.4. The Service Provider has a liability insurance contract with an insurer, setting out the insured sum per insured event at the rate provided for in legislation.
I agree to the data protection terms and conditions of BARIATRIC SERVICES AS and the general terms and conditions of providing healthcare services.
Phone
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