EL-ESSAWY HOLISTIC CARE CENTRE
94 HARLEY STREET, LONDON, W1G 7HX
Patient Personal Details
&
Consent Form.
Name……………………………………………………….………………………………
Address:………………………………………………………………………………………………………….
Date of Birth:…………………………………………………………………………………………………..
Contact Phone numbers: 1.……………………………2. …………………………………………….
Email Address:………………………………………………………………………………………………..
Occupation:…………………………………………………………………………………………………….
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I do hereby give my primary consent for examination, care, treatment and
support by Dr Hesham El-Essawy of El-Essawy Holistic Care, 94 Harley
Street, London, and WG1 7HX.
I am confident that Dr El-Essawy and his team will do their utmost to
respect and protect my human rights, my dignity and my confidentiality
and to always act in my very best interest.
I would like to make Dr El-Essawy aware of my past medical and dental
history and provide all the details required and needed to help him make
proper judgement of my treatment needs.
My Past Medical History includes:
(Please give us details of any diseases or health complains that you suffered in the past, including
health problems related to your heart, lungs, liver, kidneys, blood, lymphatic system, nervous
system, immune system, digestive system, skin, hair, nails, eyes, ears etc. Please also list all
hospital admissions or visits as outpatient and their outcomes. Please mention any relevant issues in
you family history.)
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My current Medical condition:
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Detailed Medical History Questionnaire
1. Are you on any medication?
Yes. No.
2. (For ladies) Are you likely to be pregnant? Yes. No.
3. If so, when is your due date? ……………………………
4. Are you taking steroids?
Yes. No.
5. If so, please give details……………………………………
6. Have you ever had Rheumatic Fever?
Yes. No.
7. Do you suffer from any allergies?
Yes. No.
8. Have you ever had Jaundice?
Yes. No.
9. Have you ever had Hepatitis?
Yes. No.
10.
Have you ever had Heart trouble? Yes. No.
11.
Have you ever had chest trouble?
Yes. No.
12.
Have you ever had a bad reaction to
Local and/or General Anaesthetics? Yes. No
If so, pleas give details…………………….………..
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Have you ever had any bleeding disorders? Yes. No.
Do you suffer from fainting attacks?
Yes. No.
Do you suffer from high blood pressure? Yes. No.
Do you suffer from Diabetes?
Yes. No.
If so, what do you take for it?
Yes. No.
Have you ever had kidney disease?
Yes. No.
Have you had any hospital treatment?
Yes. No.
If so, please give details…………………………………….
Do you smoke?
Yes. No
Do you drink alcohol?
Yes. No.
Is there anything in your medical history that we
should know about?
Yes. No.
 If so, please give full details……………………………….
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Please sign and date.
Doctor’s signature
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My past dental history includes:
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Please indicate and rate any suffering from the following conditions.
0 (none existent)-10 (extreme) suffering.
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Tiredness and loss of energy:
Constantly feeling unwell:
Waking up tired:
Sleep disturbances:
Digestive problems, bloated:
Loss of concentration:
Short-term memory lapses:
Feeling cold/cold extremities:
Feeling as if a small potato is
stuck in the throat:
Frequent cold, sore throat
Mouth ulcers:
Anxiety:
Depression:
PMT:
Headaches:
Migraines:
Skin problems:
Hair problems:
Nail problems:
Tingling sensation:
Fine tremors:
01 2 3 4 5 6 7 8 9 10
01 2 3 4 5 6 7 8 9 10.
01 2 3 4 5 6 7 8 9 10.
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Please mention any other symptoms that you are suffering from:
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I REQUEST amalgam removal, using Dr El-Essawy’s protocol, which I
have studied and am fully aware of all it entails, including the
alternatives, the possible benefits and possible risk factors.
Patient signature…………………………………………Date……………………
 I do/do not give my consent to be examined by Dr El-Essawy and/or any
of his associates.
 I do/do not consent to having a panoramic x-ray taken and I do accept
that without such an x-ray Dr l-Essawy might not be able to judge my case
fully or inform me fully of every thing involved in my case.
 When Dr El-Essawy is able to reach a diagnosis of my condition,
I understand that Dr El-Essawy will discuss clearly with me his proposed
treatment plan, explaining the risks, benefits, and alternative
options. Both he and I will endeavour to reach an agreed treatment plan.
My signature at the end of this form is to be taken as a confirmation of the
above as described to me.
 I understand that I am free to change my mind about going ahead with
the proposed treatment at any time and that I must make Dr El-Essawy
aware of that fact verbally and in writing (email) immediately.
 Before going on to treatment I understand that Dr El-Essawy will prepare
an Estimate Form where all the treatment items will be set clearly
together with the costs of every item. If it happens that I am not clear
about any item on the plan I shall immediately make Dr El-Essawy aware
of that fact, preferably in writing (by email).
 In the case of having my treatment done under sedation I do/do not
consent to Dr El-Essawy performing any treatment that he might find
important for my health while I am under sedation and unable to give
informed consent. An example of such treatment is when he finds decay
or that a nerve is exposed under an amalgam filling and that he will need
to do some work to avoid the possibility of post-operative pain.
 I confirm that Dr El-Essawy/his associates has given me separate sheets
of paper with detailed pre-op and post-op instructions relating to IV
Sedation.
Patient Signaure……………………………………………Date………………….…………..
 I understand that by seeking treatment from Dr El-Essawy I become an
important member of the team treating me, with full co-operation and
participation on my part in my treatment. I also promise to go strictly on
the discipline required of me to make that treatment reach a successful
conclusion. In case I am not able to do that, I will let Dr. El-Essawy know
of that fact.
 I have visited Dr El-Essawy’s website and do/do not understand its
contents, which I accept as forming an essential part of our treatment
contract and my consent.
 I have read the linked file named ‘protocol and fees’ and understand that
it forms the basis of my agreement with Dr El-Essawy.
 I understand that Dr El-Essawy will refund my fees for amalgam removal
if at the end of 18 months post-op it is found through the mercury vapour
analyser readings and BioMeridian readings that my body -burden of
mercury has not been significantly reduced, provided that I strictly
followed the essential detox protocol.
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FEES:
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I accept that the fees payable as agreed before the start of
treatment. I also consent to Dr El-Essawy drawing his fees as
agreed with me through my nominated credit or debt cards and
that he will forward a receipt to me in due course.
My nominated credit card is:
Credit Card Number:…………………………………………………………………………….
Card expiry date:………………………………………………………………….......................
Security number: …………………………………………………………………………………
My nominated Debit card is:
Debit Card Number:………………………………………………………………………………
Card Expiry Date:…………………………………………………………………………………..
Security number:…………………………………………………………………………………..
Dr El-Essawy is aware of his duties to honour and respect confidentiality and
data protection and I trust that all of my personal details will be treated with
such care and attention as is expected of him.
Signed:
Dated:
Signature of Dr El-Essawy
dated:
5
BIO-MERIDIAN TEST RESULTS
PRE-OP READING S
DATE
DATE
DATE
_______________________________________________________________________________
BEE
M
EM
MM
OTHER H.M. READINGS
ALUMINIUM
ARSENIC
CADMIUM
LEAD
L. S.
K.
L.
Candida.
F.I.
MATERIALS
NOTES
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I V SEDATION
PRE-OP & POST-OP INSTRUCTIONS
We propose to give you a sedative+ a local anaesthetic to make the
procedure easier for you to cope with. That sedative is from the Valium
family. It is not a general anaesthetic. It may make you forget everything
that took place while you are under its effect. It may make you unaware of
the passing of the time. You might find the experience rather pleasant.
We give you IV Sedation in order to ensure that you would not inhale nor
swallow any mercury vapour during the procedure. We cannot do that
without your help so please ensure that you do help us. If at any stage we
find that your safety might be compromised we will abort the procedure
instantly.
Please observe the following:
1. Have nil by mouth for 5 hours before your appointment
2. Wear comfortable loosely fitting clothe especially around your
arms, as we will need access to one of your veins to put a cannula
in.
3. Do not use nail varnish as this might interfere with our pulse
oximeter readings.
4. If there is any possibility that you might be pregnant, please have a
pregnancy test first, as we do not wish to sedate your embryo too.
5. If you are taking any medication please check with us first.
6. Please arrange for an escort from among your relatives or close
family, and explain to your chosen escort what you are generally
going to have, and ensure that your escort is able and willing to
carry out the post-op instructions, which are basically to take you
home in a car or a taxi, not on public transport, and to keep an eye
on you for 12 hours after.
7. You must not smoke
8. You must not operate any machinery
9. You must not take any important decision or sign any documents
until 24 hours post-op. That is why we would ask you to settle
your account with us before you are given sedation rather than
afterwards.
10. If you have any children, please arrange for some one to look after
them while you are recovering.
11. If you wear contact lenses please remove them before the
procedure.
Patient signature:
Date:
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Patient Appraisal and feed back Form
Please give us your appraisal of the treatment received
in our practice and feel free to make any suggestions.
How do you rate the service that we offered to you?
0 1 2 3 4 5 6 7 8 9 10
Did we meet your expectations?
0 1 2 3 4 5 6 7 8 9 10
What do you think were our strong points?
What do you think were our weak points?
How could we have improved our service to you?
Name:
Signature:
Date:
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