Phone:
416-962-4444
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Text:
647-760-3234
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About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Membership & Qualification
Our Doctors
Dr. William El Masri
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Dr. Guillermo Castillo
Dr. Waqqas Jalil
Dr. Ashwin Maharaj
NeoGraft
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction in Toronto
Body Makeover Surgery
Vaginal Rejuvenation Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Varicose Vein Treatment
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Membership & Qualification
Our Doctors
Dr. William El Masri
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Dr. Guillermo Castillo
Dr. Waqqas Jalil
Dr. Ashwin Maharaj
NeoGraft
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction in Toronto
Body Makeover Surgery
Vaginal Rejuvenation Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Varicose Vein Treatment
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Phone: (416) 962-4444
Text: (647) 760-3234
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Membership & Qualification
Our Doctors
Dr. William El Masri
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Dr. Guillermo Castillo
Dr. Waqqas Jalil
Dr. Ashwin Maharaj
NeoGraft
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction in Toronto
Body Makeover Surgery
Vaginal Rejuvenation Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Varicose Vein Treatment
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Menu
About Us
Premises Inspection Committee Report
Cosmetic Surgeons in the GTA
Setara Ghairat | Nonsurgical Treatment Specialist
Videos
Testimonials
Membership & Qualification
Our Doctors
Dr. William El Masri
Dr. Brian Yeung, N.D.
Dr. Leonard Bienenstock, M.D.
Dr. Chameli Deb, M.D.
Dr. Guillermo Castillo
Dr. Waqqas Jalil
Dr. Ashwin Maharaj
NeoGraft
Breast
Breast Augmentation
Male Breast Reduction
Breast Reduction
Before & After (Breast Augmentation)
Face
Facelift
Rhinoplasty | Nose Surgery
Chin Surgery
Eyelid Surgery / Blepharoplasty
Forehead Surgery
Otoplasty / Ear Surgery
Facial Scar Revision Surgery
Body
Brazilian Butt Lift [BBL] or Gluteoplasty
Abdominoplasty / Tummy Tuck
Liposuction in Toronto
Body Makeover Surgery
Vaginal Rejuvenation Surgery
Weight Loss
Naturopathic Weight Loss
Lap Band Surgery
Weight Loss With Gastric Balloon
Non-Surgical
Non-surgical Skin Treatments
Fillers & Injectables in Toronto
Treatments
Full Face Lift With Ultherapy
Ulthereapy Non-surgical Facelift
Vitamin Injection Therapy
Skin Rejuvenation Therapy
Jeunesse FUE Hair Transplant Treatment in Toronto
Microdermabrasion Treatment in Toronto
Mole Removal Treatment in Toronto
Anti Aging Bio-Identical Hormone Testing and Replacement (BHTR) Toronto
Photo Facial Treatment in Toronto
Derma Filler Esthelis
Eyelash Extensions in Toronto
Chemical Peels in Toronto
Laser Hair Removal
Authoritative Clinical Data, Peer Reviews & White Papers on Laser Hair Removal
Varicose Vein Treatment
Before & After
Blogs
Pricing
Our Pricing
FAQ’s
Cancellation Policy
Forms
La Fontaine Source De Jeunesse
Patient Health/Anesthesia Questionnaire
COVID-19 Questionnaire & Informed Consent – General
Option Weight Loss Clinic
Dermal Filler Informed Consent
Injectable Informed Consent Form
Consent for Sclerotherapy of Varicose and Spider Veins
Contact Us
Patient Health/Anesthesia Questionnaire
Type of Operation
Surgeon
Patient Name
Date of Birth
Age
Phone Number (you can be reached)
Occupation
Marital Status
Married
Divorced
Single
Widowed
Children
Height
Feet
CM
Height
Weight
KG
LBS
Weight
Family Physician
Family Physician phone #
Do you have any ALLERGIES?
No
Yes
Have you ever had Anesthetic?
No
Yes
Are you pregnant or do you think you could be pregnant?
No
Yes
Date of Last menstrual Period
Do you have any Loose teeth, Caps, Crowns, Bridges, Dentures or other removable Dental Appliances?
No
Yes
Have you ever Smoke?
No
Yes
Any cough?
No
Yes
Do you take, or have you ever taken any ADDICTING DRUGS?
No
Yes
How much alcohol do you drink in a week?
Angina or chest pain
No
Yes
Chest pain climbing one flight of stairs or / at night
No
Yes
Heart attack / Heart Failure
No
Yes
High blood pressure
No
Yes
Palpitations / Irregular pulse / Heart murmur
No
Yes
Pacemaker / Internal Defibrillator (ICD)
No
Yes
Bypass surgery /Angioplasty / Stent
No
Yes
Valve replacement / Heart transplant
No
Yes
Stroke / TIA
No
Yes
Peripheral Vascular Disease e.g. DVT, phlebitis, blood clot, aortic aneurysm, arterial or carotid bypass surgery
No
Yes
Aspirin, Coumadin, Plavix, other Blood Thinners
No
Yes
Asthma
No
Yes
Chronic bronchitis / emphysema / COPD
No
Yes
Sleep apnea (heavy snoring, choking, use of CPAP)
No
Yes
Shortness of breath climbing one flight of stairs or/at night
No
Yes
Tuberculosis
No
Yes
Any other lung problems
No
Yes
Diabetes
No
Yes
Liver Disease / Hepatitis
No
Yes
Sickle Cell Disease/Trait/or Family History of Anemia
No
Yes
Easy bleeding or bruising
No
Yes
Thyroid Problems
No
Yes
Muscular Dystrophy, Epilepsy/Seizure, Polio
No
Yes
Kidney problems
No
Yes
Acid reflux or frequent heartburn / Ulcer / Hiatus Hernia
No
Yes
Rheumatoid arthritis / Aankylosing spondylitis
No
Yes
Chronic Neck / Back / Muscle Injury or Problems
No
Yes
Have you taken Prednisone / Steroid medication in the last 6 months?
No
Yes
Have you ever had a blood transfusion?
No
Yes
Do you or have you ever had any serious illness (Cancer, Chemotherapy etc) not mentioned?
No
Yes
Do you have any past surgeries?
No
Yes
Are you taking any medications including over-the-counter drugs, puffers, insulin:
No
Yes
List of Medication
Consent
By initiating this form, I confirm that my answers are true and have been answered to the best of my ability.
Signature
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