Patients who are exhibiting any symptoms (unexplained fever, cough, shortness of breath, chills, muscle pain, headache, sore throat, and/or new loss of taste or smell) should have their surgery postponed until 14 days symptom free before any surgical or invasive procedure.
We need to collect some important medical information about you before your procedure at The Harley Street Hospital. This information will be kept confidential.
Please fill the form FULLY in order for us to prepare for your surgery.
Please email us on [email protected] or phone on "02039738842" if you have any queries or need help in completing the form.
Please contact your Consultant if you have any doubts about the procedure or you would like to have more time to consider your options.
Proceed with completing the form only if you understand your alternatives and want to go ahead with the proposed procedure.
You need to know ;1. Type of Anaethetic you will have for the procedure2. Details of your medical condition(s) 3. Your medications4. Your height and weight5. your next of Kin (name, phone and address)6. your GP details (you may decline)
It usually takes 10-15 minutes to fill the form.
Required for patient information leaflets and communications about your planned operation. This confirms that you have given consent to us for using your email for important communications.
Please state GP (general practitioner) name, Practice and Practice address. We may contact your GP about your health and your operation unless you decline. (Optional)
All patients undergoing surgery need to provide us with next of Kin details. We would only contact your Next of Kin in the unlikely event of an Emergency.
We strongly recommend that you have a responsible adult to take you home by private transport and stay with you for at least 24 hours after the surgery.General Anaesthesia/ Sedation will cause some drowsiness which may be prolonged. Please also keep a phone with you after your discharge which can be used to make calls if you feel unwell after the surgery.
Please confirm that your surgeon has explained the nature of the Procedure that you will be having.You should only proceed if you understand the risks and benefits of the procedure.You should get all the information about your procedure before being admitted.
One of the rare complications is bleeding which is stopped in most cases with some extra surgical measures by your consultant. In extremely rare circumstances, blood transfusion may be required. Please state if you have any objections to this.
We advise you to take your normal medications on the day of surgery such as blood pressure tablets.Avoid taking any blood thinning medications. Please give us the full list of your medications so that we can advise you before your surgery.
We may need to postpone your surgery if you have taken the medications that can cause bleeding problems during surgery.
Please include your Contraceptive or Hormone Replacement Therapy medications if this is applicable to you
Please make sure you put height in metres5ft 8inches = 1.72 metres5ft 10inches = 1.77 metres6ft = 1.83 metres
Weight must be in Kilos12 Stones = 76.2 kg13 Stone = 82.5 kg14 Stone = 89 kg15 Stone = 95.3 kg
Please answer the following questions to determine whether you are at risk of having Obstructive Sleep Apnea (OSA).
We need to know if you have any medical problems that might need to be treated before your operation, or if you need special tests/care before, during or after the surgery.
The tests you have will depend on what operation and the kind of anaesthetic you are having.
These tests might include blood tests, urine tests and ECG.
We may need to arrange the above tests a few days before your operation.
You may be asked to take additional medication prior to surgery to reduce the stomach acid. This will depend on the type of anaesthesia you will be given.
Creutzfeldt-Jakob disease (CJD) is a rare and ultimately fatal degenerative brain disease. In healthcare settings, we are required to collect this information to minimise the transmission to others.
Have you ever been diagnosed with the following by your doctor?
Diathermy may be used during your operation. If you have a metal implant, extreme heat can cause a shock or burn where the implant is. Please let us know any metalwork or implants you have in your body so that we can take precautions during surgery.
Recreational ‘street’ drugs, including legal highs,can cause serious and possibly life-threateningreactions. These drugs last a differing amount of time in your system and can interact with thegeneral anaesthetic in unexpected ways causing complications that may be fatal.
Please advise us of any recreational drug usage so we can make a plan to ensure your procedure is carried out as safely as possible.
If you smoke, you should think about giving up. The longer you can stop the better. If you stopsmoking for a day or two, your blood cells will be able to carry more oxygen around your body.
If you can stop for about six weeks before you come into hospital, you are also less likely to get a chest infection, a wound infection or delayed wound healing after the operation
MRSA stands for (M) Meticillin (R) Resistant (S) Staphylococcus (A) Aureus. This is a common germ that is found on the skin and in the nostrils in about a third of healthy people. It can cause infections through the surgical incision.
An MRSA Screening swab is used to detect whether it is present on your skin prior to surgery. If present, you will be given a special solution and medication for a few days before your surgery.
This test is only required for certain patients having open surgery.
All patients undergoing a Day Surgery Procedure must take the following precautions.
For your safety, Please tick each box to confirm your understanding.
Illness before surgery can increase the risks of anaesthesia and therefore your procedure may need to be postponed until you are better.
Please inform us immediately if you develop diarrhoea and vomiting, and/or respiratory tract infection and/or high temperature.
It is important that your stomach is empty as this reduces the risk of vomiting during the procedure. Stomach contents can come up the back of the throat and get into your lungs which can be very dangerous.
After a procedure where you have been nil by mouth, we will offer you a Light Meal.
We source our food from respectable food retailers but cannot guarantee that all food and drinks are allergen-free. We advise you to bring your own food if you have severe food allergies.
You have told us that you have a Food Allergy.
We would recommend that you bring your own snack if your food allergy is severe as we cannot guarantee that our sandwiches will be allergen free.
I agree with Hospital Terms and Conditions
After clicking the "Submit" Button, please be patient as it may take upto 1 minute for the form to be processed. If there are errors or the form is incomplete, you will be asked to correct the errors and press the "Submit" button again.
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