Patient Questionnaire

Thanks for providing your deposit! Now, please tell us more about yourself so we can provide the right care and do it safely. If you have questions or difficulties, please call and we can do this part together.

Which procedure(s) would you like to have?
Please select one or both. The fee for one procedure is $1,699. If you want both, there is a $150 discount available, making the total $3,248.
This field is required.

Our “right away” procedure date is Friday, February 30, 2026 . We will call you to set the appointment time and to talk about how to get ready.

When would you like to have the procedure?
Choose your preferred urgency.
This field is required.
Please enter your first name.
This field is required.
Please enter your last name.
This field is required.
Please enter your date of birth (MM/DD/YYYY).
mm/dd/yyyy
This field is required.
What is your address?
Please enter your full address.
This field is required.
This field is required.
This field is required.
Province
This field is required.
This field is required.
Country
This field is required.
Please enter your phone number.
This field is required.
Please provide the name of a contact in case of an emergency.
This field is required.
Please provide your emergency contact’s phone number.
This field is required.
Please enter your RAMQ number if you have one.
This field is required.
Please list the names of the doctors. (Hint: shift+enter starts a new line.)
Please provide details about your reason for the procedure. (Hint: shift+enter starts a new line.)
This field is required.
Do you have any cardiac illnesses?
Please indicate if you have any cardiac illnesses.
This field is required.
Do you have any breathing difficulties?
Please indicate if you have any breathing difficulties.
This field is required.
List any medical conditions you may have. (Hint: shift+enter starts a new line.)
List any surgeries you have undergone. (Hint: shift+enter starts a new line.)
Do you take any blood thinners?
Please indicate if you take any blood thinners.
This field is required.
Do you take any other medications?
Please indicate if you take any medications, prescription or non-prescription.
This field is required.
List any medications you are currently taking. (Hint: shift+enter starts a new line.)
Do you have any allergies?
Please indicate if you have any allergies.
This field is required.
List any allergies you have. (Hint: shift+enter starts a new line.)
Is there any gastrointestinal cancer in your family?
Please indicate if there’s a history of gastrointestinal cancer in your family.
This field is required.
If yes, please specify the type of cancer:
Select the type of cancer if applicable.
This field is required.
Please enter ie: father, sister, aunt, etc.
This field is required.
Please enter your height in feet/inches or in cm. Ie: 6’1″ or 180cm
This field is required.
Please select your weight in lbs or kg. Ie: 85kg or 180lbs.
This field is required.
Consent
Please read the consent form for the medical procedure(s) and data consent. This document will be sent to you by email in a few days for more formal signing using the Xodo Sign application. We will send you an email to ask you to opt-in to our mailing list to receive general promotions, newsletters and updates.

Consent Form

If you do not agree, please close your web browser and clear your browser cache now. Your data has not yet been sent to our servers. Contact us to arrange for a refund of your deposit.
This field is required.

Book Procedure

Next Available Date

Friday, February 30, 2026

Book Now

(Hint: scroll to close)

This will close in 20 seconds

Scroll to Top