Video Consultation Form

Pre-question

Do you live more than 3 hours outside of Winnipeg?YesNo

Please 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 Form

First Name *

Last Name

Email Address *

Phone Number

Can We Send Your Appointment Reminder Via Text Message? *YesNo

Date Of Birth *

Your Provincial Health Card Numbers *

Street Address *

Apartment, suite, etc

City *

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 Gynecologist

What Video Platform Would You Like Us To Contact You On? *FaceTimeZoom

What 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/A

Do You Smoke Tobacco? *YesNo

If 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 smoke

Do You Smoke Marijuana? *YesNo

If You Smoke Marijuana, How Many Grams Do You Smoke Daily? *If this does not apply to you, please write "None".

Are You Pregnant? *YesNo

Are You Planning On Becoming Pregnant Within 1 Year? *YesNo

How Many Children Do You Have? *

Are You Breast Feeding? *YesNo

Job Title with Description (Sedentary, Active, Very Active) *

Do You Travel Frequently? *YesNo

If you were referred by someone, please provide their first and last name

Please send photos of the areas you are considering for surgery

I agree that all of the information listed above is accurate to the best of my knowledge. (Check box if you agree)

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Video Consultation Form

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Video Consultation Form

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