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  • Teleconsultation Request

    1. Please complete the information required below. 
    2. If you have already sent in your medical information you will not need to submit again.  Please indicate YES, please use my existing information and advance to the last page, and submit. 
    3. Your Patient Navigator will confirm timing and surgeon availability in advance of the session.
    4. If the dates are not available, alternate dates will be provided.
    5. All teleconsultation instructions and access will be provided at least 48 hours prior to your session. Please ensure you notify us with 24 to 48 hours of your scheduled session if you are unable to attend and we will reschedule. 
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  • Patient Information

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  • Medical

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  • Your Family Medical

    Please indicate if you have a history of these conditions in your family. 

  • Your Personal Medical

    Please indicate if you have any of these conditions.

  • Habits

    Please describe your current personal habits

  • Women

    This section is for women only

  • Medical Files

    Please upload your medical files and/or your pathology report securely.
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