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Medical questionnaire

Complete this form to facilitate your first visit.

If you have already scheduled an appointment with us, you can facilitate your first visit by filling out this medical questionnaire and then by clicking the SEND button at the bottom of the page. This confidential information will only be reviewed by your surgeon at the time of your appointment.

If you prefer to print, fill it out by hand and bring it with you at your appointment, click here. You can also send it by email to

Personal information

Medical informations

have you ever had or are being treated for the following:

Women only

Allergies, medications and other information

Are you allergic to, or have ever had an unusual reaction to any of the following?