Schedule a Consultation

Kindly fill out the form provided below. Following this, we will promptly confirm the date and time of your appointment with one of our colorectal surgeons to address your health concerns, diagnostics, and treatment strategy.

Please be aware that in most cases, we require the referral slip before your scheduled appointment.

    PERSONAL INFORMATION

    MEDICAL HISTORY

    Do you have a family history of colon or rectal cancer? (Immediate family only: mother, father, sibling)

    Do you have a personal history of colon or rectal cancer?

    If yes, when was it discovered?

    Do you have a history of colitis (Crohn’s, ulcerative, etc.)?

    Do you have a history of diverticulosis or diverticulitis?

    Do you have a personal history of colon or rectal polyps?

    Please check if you ever had:

    Have you ever had a colorectal examination?

    If yes, please check what type:
    If yes, please indicate when & where was your last exam:

    Have you noticed blood:

    Have you noticed a change in your bowel habits recently?

    Are you taking any blood thinners?

    If yes, please indicate below name and dose:

    Are you currently using a wheelchair for mobility?

    Please attach your referral slip: