GP Consultation Form

In preparation for your GP consultation at Kinvara Private Hospital, please complete this short form.

Name *

First

Last

Address *

Address Line 1

City

Postal Code

Date of Birth *

Phone Number *

Email *

What problem did you want to discuss? *

When did the problem start? *

Do you have any medical problems? e.g asthma, diabetes, high blood pressure etc? *

What medications do you take? *

Do you have any allergies to drugs or dressings? *

No Yes

Do you smoke or vape? *

No Yes

Do you require assistance for your consultation? *

No Yes

Agreements *

I hereby consent to the collection, storage, and use of my medical information for the purpose of diagnosis, treatment, and healthcare management, with the understanding that my data will be handled in compliance with all relevant privacy and confidentiality regulations.I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my participation in aesthetic procedures. I will inform Kinvara Hospital to any future changes in this information.

Today's Date

8 July 2026