IMPORTANT: IF KNOWN, PLEASE COMPLETE DATES BELOW.
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.
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.
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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