Patient Health Questionnaire

Your privacy is important to us. The information you provide is stored securely and will only be accessed by authorised Metropolitan Anaesthesia Staff.

The fields indicated with an ‘*’ are required.

Estimates of costing cannot be issued straight away. Once the completed questionnaire is forwarded to the Doctor, they will advise of the Anaesthesia fee and a staff member will be back in contact via phone or email with the Anaesthesia estimate of costing.

***IMPORTANT***

PATIENT PRE-SCREENING

Please advise us if you answer YES to any of the following

1. Have you left or transited through Mainland China in the last 14 days and/or returning from Italy, Iran, South Korea, Cambodia, Hong Kong, Indonesia, Japan, Singapore and Thailand. Or travelled anywhere in the last 14days.
2. Have you had contact with a confirmed case of Corona Virus in the last 14 days
3. Do you have any signs and symptoms of a respiratory infections such as:
   1. Fever
   2. Sore Throat
   3. Cough
   4. Difficulty Breathing

If you answered YES to any of the above, do not attend your appointment.

Please call our rooms to schedule a phone or video consult.