Please fill in this on line pre admission form without any obligation. The information will help us assess your condition and general fitness for the operation required. The information is protected by EU data laws and will only be utilized for your direct benefit by authorized hospital personnel
What is the operation or procedure you require? :
 Name: *
Date of Birth *
Address *
Telephone Number *
Email Address *  
Occupation
Nationality
Religion
Next of Kin *
Next of Kin's Address *
Next of Kin's Tel No *
G.P.'s Name
G.P.'s Telephone No.
Consultant's Name
Consultant's Telephone
What is your weight and height? :
How many cigarettes do you smoke every day?:
How many units of Alcohol do you drink every week?

Have you had problem with Anaesthetics?  If so please give a short description :
Is there a family history of any problems with Anaesthetics?
Is this your first operation? :
Do you have diabetes? :
How is it controlled? :
What was your latest blood sugar level? :
Have you ever had liver disease or been jaundiced? :
Have you ever had any type of Hepatitis? :
Do you have any allergies? :
Are you allergic to Penicillin?:
Do you have any crowns, loose, or artificial teeth? :
Do you wear contact lenses? :
Are you taking any medication? :
Do you have any special needs? :
Do you have any a visual impairment? :
Do you have a hearing impairment? :
Have you ever had any have heart problems or rheumatic fever ?
Do you suffer from high blood pressure ? :
What was the last blood pressure reading? :
Do you get breathless or chest pains on exercise or at night? :
Do you get swollen ankles? :
Have you ever had kidney disease? :
Do you have asthma, bronchitis, or other chest diseases? :
Have you ever had a convulsion or a fit? :
Do you suffer from arthritis or any muscle disease? :
Previous Operations
Have you had any operations in the past? : please list
Did you have any complications such as DVT? :
Do you suffer from any allergies? :
Are you taking any prescribed medication? :
Have you had any serious illness and or medical conditions in the past? :
Drugs
Have you ever taken any Drugs even on recreational basis? :
If yes when was the last time you took non prescribed drugs? :
Females
Are you pregnant? :
If no, date of last period :
Additional Information you think may be relevant or that we should know. If necessary please send by seperate e-mail to biomed@stphilips.com.mt
Financial:

We offer various types of fixed cost surgery packages - depending on the time of the year as well as the type of hotel facilities required by patients travelling to Malta for treatment.

If you already have a quotation for this operation from someone else - please let us know to see if we can give you a better offer.
What would you consider a reasonable price to pay for this procedure in Euros or in Sterling? :
Method of Payment
Please note that credit or debit cards when used for overseas payment may incur bank charges which remain your responsibility - the most cost effective way to effect payment is by bank transfer.
Are you covered by Insurance?:
Name of Insurance:
Policy Number:
Once we receive this form we will process the information you submitted as quickly as possible and we will give you our initial assessment of your fitness or otherwise for the procedure and we will also give you our quote for fixed cost surgery. Data Protection Any information you submit is protected by data protection laws of the EU We will only use the information for your direct benefit and the information submitted will only be shared with our staff and medical professionals who will be directly involved with your care.
* Required Information