Patient Details

Full Name:

MRN:

DOB / Age

Phone / WhatsApp:

Emirates ID:

Allergies (drug & reaction):

Clinical History:

Past Medical History:

Past Surgical History:

Medications (incl. Vitamins, Herbs, Supplements):

Physical Exam / Key Findings:

Referrer & Planned Procedure

Referring Physician:

Dr. Dora Evangelidou

Clinic:

Skin Experts Polyclinic

Contact number:

+971 58 566 3900

Contact (nurse/email):

[email protected]

Planned Procedure:

Planned Date:

Anesthesia Plan:

☐ GA

☐ IV sedation

☐ Local

☐ TBD

Reason / Type of Referral (tick all that apply)

☐ Pre‑operative clearance   

☐ Specialist opinion   

☐ Abnormal pre‑op finding investigation

☐ Chronic condition management   

☐ Medication optimization prior to surgery

☐ Clearance after imaging findings   

☐ Other:

Specialty

☐ GP   

☐ Hematology   

☐ Cardiology   

☐ Endocrinology   

☐ Anesthesia   

☐ General Surgery (breast surgery specialist)

☐ Other:

Pre‑operative Investigations

Blood Work: ☐ Normal  

☐ Abnormal (attach)

☐ Bilateral Breast Ultrasound 

ECG: ☐ Normal

☐ Abnormal (attach)

☐ Mammogram   

☐ Other:

☐ Other:

Abnormal Findings Summary:

Requested Actions & Targets:

☐ Provide clearance for surgery from the treating physician of any pre‑existing condition

Condition: ______________ Treating physician Specialty: ______________

☐ Further investigation of newly identified abnormality:

☐ If no further action is needed, issue report stating “no action required prior to elective surgery” so we can proceed so the patient can proceed with elective surgery

☐ If the patient is not fit for elective surgery, disclose in report with reasons and corrective actions

☐ For BIRADS 3 findings: confirm no further investigation required other than 6‑month follow‑up prior to surgery

☐ Confirm chronic status of conditions (e.g., thalassemia carrier anemia that cannot be normalized) when Hb normalization is not achievable

☐ State explicitly if new abnormalities require action or not prior to surgery

☐ Targets (if applicable): Hb ≥ ___ g/dL; HbA1c < ___%

☐ Other:

Attachments Sent:

☐ Blood Work   

☐ ECG   

☐ Imaging Report   

☐ Imaging DVD