Menu

Online Medical History Questionnaire

Please answer as many questions as possible.

Please note: this form is multiple pages, please click the Submit button on the final page to ensure this reaches our team. You will see a Thank You page when the form is completed.

Patient Information

Patient’s Name

Date of Birth

Patient's Contact Information

Patient’s Emergency Contact Information

Patient’s Doctor Information

No
Yes

Please contact your family doctor to see if you need to be seen before you operation.

Are you under the care of a heart, lung or kidney doctor?

If yes, please tell us his or her:

Please notify them of your surgery in case they need to see you before your operation.