Family Doctor's Name
Todays Date
First Name
Last Name
Email
Phone
Date of Birth
Age
Health Care Number
Street
City
Province
Postal Code
When was the first day of your most recent menstrual cycle?
Date of hysterectomy, if applicable?
Comments
Consult Fees I understand the initial consult fee is $295, and each follow-up fee is $75 for this service.
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