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TRUST Surgery Consultants Application

Client Information

Surgery Details

Date of Surgery (or planned date):
Year
Month
Day
10. Is this your first round of surgery?
Yes
No

Surgeon Info & Surgery Location

Will your surgery be done locally or abroad?
Local (Toronto or Surrounding Areas)
Abroad (International)
Within Canada
I'm still exploring my options
Is your surgeon affiliated with our post-op care providers?
Yes
No
I'm still exploring my options
Will you be staying at a recovery house or hotel post-surgery?
Recovery House
Hotel
I'm still exploring my options
Other

Travel & Arrival

What is your arrival date back into Canada (if traveling for surgery)?
Year
Month
Day
Will you need airport pick-up or drop-off services?
Yes
No
I'm still exploring my options
Will a family member or companion be assisting you post-surgery?
Yes
No
Still Undecided

Medical History

Do you have any chronic illnesses or conditions?
No
If yes, please list them:
Do you currently take any prescription medications?
No
If yes, please list them:
Do you smoke or vape?
Yes
No
Occasionally
Do you consume alcohol?
Yes
No
Occaqsionally
Have you ever had complications with anesthesia or previous surgeries?
Yes
No
Are you currently seeing a doctor or specialist for any reason?
Yes
No

Pre & Post-Op Needs

Additional Information

How did you hear about Trust Surgery Consultants?
Instagram/TikTok
Your Website
Google
Referral
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