Request Appointment

We’re glad you’re thinking about taking the next step!

Following is a short form to collect your basic information.  To complete this, you’ll need your contact information, your medical information (like the name of medications and allergies) and a copy of both sides of your health insurance card (if you have insurance you plan to use).We collect this information so we can get back to you with the most accurate information possible.

Request Appt
Language preference
Preferred location for surgery *


for example, lisinopril, 20 mg
for example, one tablet twice daily

Medication Allergies

You have the option of using medicine prior to the procedure to relax you. Many patients decide they don't need this. We will discuss it more at the pre-procedure consultation. Would you like to have the option of using pre-procedure medication?
Have you fainted with medical procedures?
Do you have a history of genital or urinary conditions? *
Please mark any you've had, explain something else OR "No genital or urinary conditions for me"
Are you in a long term relationship?
Please check here if you are a current Trailhead Clinics member
You can join the video consultation from a phone or computer. What device will you be using for that session, and how do you prefer to connect? *

Consent for Treatment, Privacy Policy and Use of Electronic Communication

Acknowledgement of Consent for Treatment and Privacy Policy *