Please check box for any of these medical conditions you have or have a history of, then fill out box below with the date of diagnosis, treatments received and other necessary information.
PLEASE TAKE YOUR TIME TO REVIEW THE FOLLOWING:
Gynecologic History (women only)
Truthful Statements – Terms and Conditions
I agree the statements I’ve made above are truthful, honest, and accurate. I understand that if I lie, mislead or fail to tell the truth, there can be serious consequences including, but not limited to: my physical wellbeing and health, mortality (death), complications, poor surgical outcomes, I may incur additional fees, and may cause the surgery to be cancelled without any right to money already paid.