¡Nos alegra que esté pensando en dar el siguiente paso!
A continuación se muestra un formulario breve para recopilar su información básica. Para completar esto, necesitará su información de contacto, su información médica (como el nombre de los medicamentos y las alergias) y una copia de ambos lados de su tarjeta de seguro médico (si tiene un seguro que planea usar).
Recopilamos esta información para poder comunicarnos con usted con la información más precisa posible.
¡Gracias!
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Medications

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 *

Physician--Consult

Procedure