: : Plastic Surgery Galway : :

Mr. Thamir Ismael

MB FRCSI, Hand Dip (FESSH). FRCS (Plast)
Consultant Plastic Reconstructive, Hand and Aesthetic Surgeon

Tel : 091 759764
Email : secretary@plasticsurgerygalway.ie

This form is for Doctors only. For general query, please consult your GP.

Patient's Name *
Patient's Age *
Patient's Address
Patient's Phone Number *
Description of the Issue
Skin Diagnosis
Cosmetic Diagnosis
Hand Diagnosis
Urgency of the Issue
Existing Medical Conditions
Other Medical Issues
Patient's Medications
Patient's Allergies
Does the Patient Smoke?
Referring Doctors Name *
Referring Doctors Phone *
Referring Doctors Email
Any Additional Information