1Patient Details2Surgery Details3Patient ExpectationsRevision surgery can be incredibly complicated and has high rates of patient dissatisfaction. A surgeon must contend with inflammation, unpredictably located scar tissue, and altered underlying anatomy, all of which can pose difficulties for achieving the desired outcome. It is important therefore that they have all the facts in front of them when they consider a case. Using the form below can you please provide as much information as possible regarding your surgery and the outcome you are seeking.Once you have submitted your form the case will be assessed by Dr Anh, this is a complimentary service that we offer. This will take around 7 days. Once your case has been assessed our team will reach out and advise how to proceed.Name*Date of Birth DD slash MM slash YYYY Phone*Email* OccupationDo you have full vaccination for COVID-19?* Yes NoAre you currently, or have you ever been, involved in a medico-legal dispute?* Yes NoDate of Original procedure* DD slash MM slash YYYY What procedure was performed?*Where was the procedure performed?*Who performed the procedure?*Did you have any complications during recovery? If so please explain.*Please upload some images that you feel adequately highlight your concern area. Drop files here or Select filesMax. file size: 20 MB, Max. files: 4.Do you have your operation record? MRI, Ultrasound, surgeons report? Etc Drop files here or Select filesMax. file size: 20 MB, Max. files: 3.Please provide any details about your case you wish us to know.On a scale of 1-10 where 1 is extremely poor and 10 is perfect, how would you rate the area of concern?* 1 2 3 4 5 6 7 8 9 10In a scale of 1-10 where 1 is extremely poor and 10 is perfect, if we conducted treatment to improve the area, what score would make you happy?* 1 2 3 4 5 6 7 8 9 10What would a good outcome look like to you? ie 30-40% improvement in the area, etc.*PhoneThis field is for validation purposes and should be left unchanged.
