FBC - Video Consultation FormPre-questionDo you live more than 3 hours outside of Winnipeg?YesNoPlease note:We are only accepting video consultations for patients who live over 3 hours outside of Winnipeg. For general inquiries, please fill out our "Contact us form" or call one of our Patient Coordinators at (204) 885-1419.Consultation FormFirst Name *Last NameEmail Address *Phone NumberCan We Send Your Appointment Reminder Via Text Message? *YesNoDate Of Birth *Your Provincial Health Card Numbers *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Which Surgeon Are You Seeing? *Dr. Avi Islur, Plastic SurgeonDr. Ryan Mitchell, Plastic SurgeonDr. Michal Brichacek, Plastic SurgeonDr. Heather Diamond, Aesthetic GynecologistDr. Premal Patel, Aesthetic UrologistWhat Video Platform Would You Like Us To Contact You On? *FaceTimeZoomWhat Procedure(s) Are You Interested In? *On A Scale Of 1 to 10 What Is Your Level Of Interest For Surgery? (1=Low, 10=High) *Do You Have An Ideal Time Frame For Surgery? *List All Medications (Including Vitamins and Supplements). *If this does not apply to you, please write "None". *List All Medical Conditions (ie: Thyroid, Diabetes, etc.) *If this does not apply to you, please you write "None"List All Allergies. *If this does not apply to you, please write "None". *List Past Surgeries. *If this does not apply to you, please write "None". *Height *Weight *Outside Of Pregnancy, Have You Lost Or Gained A Significant Amount Of Weight? *If yes, please provide details. If this does not apply to you, please write: N/ADo You Smoke Tobacco? *YesNoIf You Smoke Tabacco, How Many Cigarettes Do You Smoke Daily? *If this does not apply to you, please write "None".If You Smoke Are You Willing To Quit In Order to Have Surgery? *YesNoI do not smokeDo You Smoke Marijuana? *YesNoIf You Smoke Marijuana, How Many Grams Do You Smoke Daily? *If this does not apply to you, please write "None".Are You Pregnant? *YesNoAre You Planning On Becoming Pregnant Within 1 Year? *YesNoHow Many Children Do You Have? *Are You Breast Feeding? *YesNoJob Title with Description (Sedentary, Active, Very Active) *Do You Travel Frequently? *YesNoHow Did You Hear About The First Glance? *Google SearchFriend or RelativeFirst Glance WebsiteRateMDRealSelfReferred by DoctorFacebookInstagramIf you were referred by someone, please provide their first and last namePlease send photos of the areas you are considering for surgeryDrag and Drop (or) Choose FilesI agree that all of the information listed above is accurate to the best of my knowledge. (Check box if you agree) SubmitPlease do not fill in this field. First Glance Rewards®Join the First Glance Rewards Program®Collect points every time you visit. As a member, you’ll save on your favourite treatments. SubmitPlease do not fill in this field.