Supamitr-Sena
• Appointment form

Your appointment — online

Schedule your appointment at Supamitr-Sena Cataract Clinic using the form below.

What we need:

Your personal details, reason for appointment, and your preferred date(s).

What's optional (but recommended):

You can supply your medical details (medical history, allergies, current medication etc.) in advance. Doing so takes the stress out of supplying this information when you first register at our hospital. It gives our personnel the chance to assess your information, and to contact you if there are any questions, or issues that you may need to discuss with your local doctor before proceeding with surgery.

Filling in the questionaire is a win-win situation for all! Your information is of course treated completely confidentially, in full compliance with national laws and regulations concerning personal and medical data.

How this works:

Shortly after sending off the form, you will receive an automated email, confirming that your data has been received by the hospital. Our staff will later contact you per email with a suggestion (or suggestions) for an appointment. Please note that due to our workflow, we are not able to make appointments for a precise time; you will instead be given a time slot, such as "between 09:00 and 11:30".

Personal data:

First name *:
Last name *:
Birthdate *:
Gender *: male female
Nationality *:
Passport nr. *:
Address *:

Home phone *:
Work:
Mobile *:
Email *:

Previous patient at our hospital:

Appointment for *: eye examination
cataract surgery
knee replacement
health check-up
other (please specify below)

Preferred date(s) *:

Notes:

* These fields are required.

Medical history & data (optional, but recommended):

Do you suffer from, or have you ever had:

Heart attack, stroke, angina or chest pain?

High blood pressure (hypertension; systolic > 140 or diastolic > 90)?

Palpitations or unusual heart beats?

Heart pacemaker / artificial heart valves?

Shortness of breath on slight exertion or at night?

Asthma, chronic bronchitis or emphysema?

Recent sore throat, flu or chest infection?

Rheumatic fever, tubercolosis (TBC)?

Diabetes mellitus (fasting blood glucose value greater than 110mg/dl)?

Hepatitis, jaundice, HIV/AIDS, liver or kidney problems?

Tendency to bleed or bruise easily, or clotting disorder?

Stomach ulcers or heartburn?

Blackouts, strokes, epilepsy, neurological or neuromuscular problems?

History of blood clots in legs or lungs?

Drug / medication and anaesthetic history:

Any other serious illness? Please describe in the box below.

Have you ever had any allergic or other adverse reactions to any medication, Xray dye, food, latex or plasters?

Have you ever had any allergic or other adverse reaction to antibiotics?

Are you at present, or have you in the last few months been on any regular medication (including any recreational and over-the-counter substances)? Please describe in the box below.

Have you ever had any allergic or other adverse reactions to any medication, Xray dye, food, latex or plasters?

Have you had any previous operations? Please list briefly with approximate dates in the list below.

General questions:

Have you or any of your family ever had any problems during or after an anaestetic?

Do you smoke, or have stopped smoking within the last 6 months?

Do you drink alcohol daily?

Do you have any special nursing requirements? Please describe in the box below.

Females: are you or could you be pregnant?

Do you have any cultural/religious needs?? Please describe in the box below.

Notes regarding the above questions: