General Information I am seeking surgery for: Cervical SpineLumbar SpineLimb Lengthening Other What is your desired date for medical treatment? Do you require assistance booking travel & accommodation? NoYes First Name Last Name Address Date of Birth Gender Occupation Email Address Phone Number Provincial Health Number Family Physician Tel. Family Physician Height Weight Medical History Summary Do you have any allergies? noYES Please describe your allergies Are you currently taking any medication? noyes Additional Medication Do you have a workplace related injury? yesno Do you have a motor vehicle related injury? yesno Do you smoke? yesno Please list any past surgeries/procedures you have had. List any past surgeries/procedures Have you had any of the following within the past 12 Months? Please attach any of the following documents/images if applicable. MRICT ScanX-rayUltrasoundBloodwork MRI CT Scan X-ray Ultrasound Bloodwork I will require assistance with booking medical tests: yes *If you have not had an MRI scan or imaging within 1 year, we request that you obtain a more recent scan. Please let us know if you need help booking or obtaining a requisition for medical testing/imaging.