            	           Sava Perovic Foundation Medical History Form 2023
            
*Complete and return this basic medical history to the Sava Perovic Foundation (notification to be sent to: <Surgery@SavaPerovic.com>) 

**If you prefer security, privacy and confidentiality, compress and encrypt your one folder containing all documents and photos (using WinZip, Stuffit, WinRAR, or 7-Zip) and send it to us via SendSpace.com and not as an email attachment.

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Name: Oliver

Surname (Family Name): Costan 

Date of Birth: 14.04.2017

Have you sent us photos showing the problems? (required) yes

Gender: male

Weight: 18.4kg

Height: 110cm

Your Body Mass Index (BMI): 15.2

You diagnosis: Proximal hypospadias. Hypoplastic spongiosum - meatus at penoscrotal junction

Have you previously had surgery of any type? 2 stages hypospadias repair and bilateral orchidopexies

What Procedures Do You Require? hypospadias repair

What Specific Results Do You Expect? We expect successfully repairing the failed hypospadias with a good final resault that would provide normal looking intimate parts that won't embarass our son in the future

Planned/Proposed Date for Surgery: August 2023

Have you made yourself aware of the risks involved in the the surgery you want? yes

Have you made yourself aware of all the possible complications that can occur from the surgery you want? 

Questions for the Surgeon: 

Your Email Address: aurelian_costan@yahoo.co.uk

Your Phone Number: (with country code) 00447393304141

Your Current Address: 51 Edgware Road, Birmingham, B23 6JH, United Kingdom

Nationality: Bulgarian

Preferred language: English

Person to Contact in Case of Emergency: Suzan Costan

Emergency Contact Person’s Email Address: suzan.alieva89@gmail.com

Emergency Contact Person’s Phone Number: 00447405910981

Do you have Hepatitis B or Hepatitis C or are you HIV+?  No

Are you allergic to any food, drug or anything else? (if yes, explain) No

Any additional information your surgeon should know but we didn't ask about? (if yes, explain) anaemia of unknown kind at birth, now resolved, currently on folic acid for 3 months

