Video Consultation Form

You must speak to one of our Patient Coordinators before filling this out.

Step 1. Call our Patient Coordinator at (204) 885-1419 to reserve your Video Consultation.

Step 2: Once you have a Video Consultation date, you can fill out the form below. All questions must be answered.

Step 3: Click “send”. The form will be reviewed by Dr. Avi Islur and his Surgical Coordinator prior to your Video Consultation.

Step 4: Dr. Avi Islur will call you at the time of your consultation. Please note that it may take 10 to 15 minutes from your consultation time for Dr. Avi Islur to call. This will only happen if consults are running behind.

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

How Did You Hear About The First Glance? *Google SearchFriend or RelativeFirst Glance WebsiteRateMDRealSelfReferred by DoctorFacebookInstagram

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

Please send photos of the areas you are considering for surgery

Drag and Drop (or) Choose Files

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

Submit

Please do not fill in this field.