Video Consultation Form

What Date Is Your Video Consultation Reserved For? *

What Time Is Your Video Consultation Reserved For? *

How Are You Calling In? (FaceTime, Skype, or WhatsApp) *

What Procedure Are You Interested In? *

First Name *

Last Name *

Email Address *

Cell Phone Number *

Address *

City *

Province *

Postal Code *

Date Of Birth (Date/Month/Year) *

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

List All Medications (Including Vitamins and Supplements). If You Don’t Take Any Please Write "None" *

List All Allergies. If You Don’t Have Any Please Write "None" *

List All Medical Conditions. If This Doesn’t Apply To You, Please Write "None" *

List Past Surgeries. If This Doesn’t Apply To You, Please Write "None" *

Do You Smoke Tobacco? (Yes or No) *

If Yes, How Often? *

Are You Pregnant? (Yes or No) *

Are You Breastfeeding? (Yes or No) *

Are You Planning On Becoming Pregnant Within The Next 6 Months? (Yes or No) *

How Did You Hear About Dr. Avi Islur? * Google SearchFriend/RelativeDoctorFirst Glance WebsiteRate MDRealSelfOutdoor AdvertisingOther

Job Title *

Do You Travel Frequently? (Yes or No) *

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

0 + 6 = ?Please prove that you are human by solving the equation *