• Teleconsultation Request

    1. Please complete the information required by the service provider below. 
    2. Our patient navigators will confirm timing and surgeon availability in advance of the session.
    3. If the dates are not available, alternate dates will be provided.
    4. 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

    Please complete the information below
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  • Surgery Details

    Please tell us the procedures you are interested in

  • IMPORTANT:  IF KNOWN, PLEASE COMPLETE DATES BELOW.

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  • Medical

    Please complete both the family and patient medical sections

  • 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 the following.  If yes, please indicate any details for the surgeon. 

  • Habits

    Please describe your current personal habits

  • Women

    This section is for women only

  • Medical Files

    Please upload your files securely.

  • Please upload the requested files requested from your patient navigator in advance of your medical teleconsultation.  This will allow the specialist or the surgeon to review your medical information in advance of your teleconsultation. 

  • Upload Files
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  • Thank You for Completing!

    PLEASE PROVIDE YOUR CONSENT BELOW

  • We will forward this information to your surgeon for review and feedback. In the interim please let us know if you have any questions. 

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