Online Preliminary Consultation Form

The Online Preliminary Consultation is a service offered to patients located outside Belgium.

More and more patients travel a long way to our clinic.

Although not strictly required, this initial remote consultation provides both patient and doctor the peace of mind that a suitable treatment may be possible, prior to do the effort to come all the way to London or Ghent.

This preliminary consultation form is meant to give Dr. De Meyere as much information as possible in order to determine whether you appear to be a suitable candidate for the desired surgery.

This preliminary evaluation by Dr. De Meyere will then be followed with a phone call covering all aspects of the procedure, recovery process and recommended length of stay. In this way you will already have a maximum of information before seeing Dr. De Meyere

Please take special care in ensuring that photos you submit are of good quality, preferably taken with a good quality digital camera. Use normal lens or zoom lens but not wide angles as this causes distortion. The image should be sharp and in-focus. Expression should be natural and relaxed. Keep the camera level with the area photographed. Please provide us a straight-on view, a 45-degree view from both sides and – if relevant- the profile views. The size if the image should not exceed 2 MB as bigger sizes might not transmit.

Please be remembered that this preliminary judgment can only lead to a preliminary judgement and that the decision whether a surgical treatment will be undertaken can only be made during a face-to-face meeting.

Please take time to fill out all questions on the form carefully and completely.

Title

First Name

Last Name

address

postcode

country

Telephone

Best time to call

Profession

Date of birth

Weight

Height

Smoking

Do you have any known allergies?

If yes, please specify

Do you take Aspirin, Ibuprofen, Nurofen, Fish Oil, Flax Oil, Omega Oil or Vitamin E?

Do you take medication to treat high blood pressure?

If yes, please specify

Do you take medication to treat hart problems?

If yes, please specify

Do you take medication to treat long disease?

If yes, please specify

Other medications taken

Alternative medicines (incl. herbal and homeopathic medicines)

Do you have any general health problems or conditions?

If yes, please describe

Have you had any previous surgery?

If yes, please list procedures, approximate dates and outcomes.

If yes, what was the type of anaesthesia?

If yes, did the anaesthesia go well?

If no, what problems did occur?

Do you usually heal well after suffering minor wounds?

If yes, please describe

you usually have prolonged bleeding after suffering minor wounds?

What type of surgery are you considering?

Please describe as specifically as possible the nature of your concern and desire for surgery

Please describe your expectations from surgery

Do you have any particular concerns regarding the surgery?

If yes, please specify

Have you already seen another doctor regarding this surgery?

If yes, please note their recommendations

Do you have an approximate time period in mind for your visit?

If yes, please specify

Will you be travelling alone?

Where will you be residing during your stay?

Do you have any special requirements we should know about?

If yes, please explain

Is there any other information you wish to share with us now?

If yes, please explain

Do you understand and accept in full the Conditions and Terms of Use for the OnlinePreliminary Consultation programme?

Type your full name to attest that the enclosed information is accurate and complete

Attaching Photos

You may attach up to 5 photos from your computer. Please review our guidelines and the photo quality/size requirements before attaching your files.

Photo Guidelines

Perspective
Keep the camera level with the area photographed. (Do not photograph upwards or downwards).
Photo 1: Straight-on front view
Photo 2 and 3: 45-degree side-view, right and left
Photo 4 and 5: 90-degree profile-view, right and left (if relevant)

Size
Images larger than 2 MB may not transmit. Cropping out extraneous detail or downsizing the image should prevent this problem.

Attach image *

Attach image

*Required to attach minimum one photo

Note: If for any reason you are unable to attach images to the form, you may email them separately along with a brief message clearly identifying yourself and the images.

Submitting your form

If you wish to save a copy of this form, please print now before submitting.