02 8073 9393

admin@drpeterlorentzos.com.au

02 8073 9300

    PRE-OPERATIVE MEDICATION & SUPPLEMENT DISCLOSURE FORM

    Patient Details

    1. Prescription Medications

    Are you currently taking any prescription medications?

    2. Blood Thinning Medications

    Are you currently taking any blood thinners or medications that affect clotting?

    If yes, please tick any that apply:

    3. Steroid Medications

    Are you currently taking steroid medications?

    4. Diabetes or Weight Loss Medications

    Do you have diabetes?

    Are you currently taking diabetes / weight loss medications?

    If yes, please tick any that apply:

    5. Over-the-Counter Medications

    Do you regularly take any non-prescription medications?

    If yes, please tick any that apply:

    6. Vitamins, Supplements & Herbal Products

    Do you take any vitamins, herbal remedies or supplements?

    If yes, please tick any that apply:

    7. Nicotine, Alcohol & Recreational Substances

    Alcohol use:

    Nicotine use:

    Cannabis use:

    Other recreational drugs:

    8. Medication Allergies

    Do you have any allergies to medications?

    Patient Declaration

    I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that failure to disclose medications, supplements, or substances may affect the safety of my procedure.

    Patient Consent:

    Lets Work Together

    admin@drpeterlorentzos.com.au

    Dr Peter Lorentzos is a highly experienced Australian-trained Orthopaedic Surgeon with an interest in sports injuries, knee and hip arthroplasty including robotic hip and knee surgery, and trauma.

    Our Services

    Quick Connect

    Copyright © - Dr Peter Lorentzos
    Designed and Developed by Webtrify.