Patient Information Forms

Please enter your details, as they appear on your passport (e.g. Joseph Jason Bloggs instead of Joe Bloggs).

This form is for data protection purposes. There is no obligation to use our free service.

By completing this form you (the patient) consent to being contacted by Surgery Now.

A copy of your medical data will be securely stored by Surgery Now and this form is to record your consent being given.

If you wish to withdraw this consent at any point, please contact us.

Click here to see Zed Doctor Platform info

Click here to see Privacy Policy

Click here to see Terms of Use

Salutation

First Name*

Last Name*

What are your symptoms? For how long?

Email*

Mobile*

Best Time To Call

Date of Birth*

Address*

Town/City

County

Eircode

PPS Number

Medical Card Number

Do You Have Private Health Insurance (VHI, Laya..)

Do You Have a UK Pension?

Where did you have a scan?

Body area Scanned

Approx. Scan Date

GP Last Name (no title)*

GP Postal Address*

GP Phone Number

Height (cm)

Weight (kg)

Do you have any of these conditions?

Have you ever had any problem with anaesthesia?

Do you smoke?

Do you take any medication? If so, which?

Do you take Blood Thinners?

Please list all medical conditions

Do have mobility difficulties? Please describe.

What are you allergic to?

How long are you in pain?

Where is the pain coming from?

Left/Right/Both

Occupation (Desk or physical)

Who have you spoken to in Surgery Now?

Where did you hear about us?

I consent to all the terms and conditions below*

I consent to allow Surgery Now to share Records and Data with our hospitals in the Surgery Now network of hospitals.
I consent to have a Zed account created so that my medical images and documents can be shared with the receiving hospitals and Surgery Now for 12 months. More information about our policy is located here.
I have read and agree to the Privacy Policy and Terms of Use
I consent to allow Surgery Now to contact me by phone, email and SMS.
I consent to allow Surgery Now to access my images and data on the Affidea platform.
I consent to allow Surgery Now to access my images and data on the Alliance Medical platform.
I consent to allow Surgery Now to discuss your loan requirements with your credit union on your behalf, if required (no medical information will be shared).
I consent to allow Surgery Now to discuss claim information with your insurance provider.
I consent to allow Surgery Now to share my contact information with the hotel when Surgery Now makes a booking on behalf of the patient.

Please accept this

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