Attending Physician’s Statement

Fill in the online form below or click here to download a PDF version of the form to fax to us.

Patient Consent
The patient is responsible for securing this information and any fees her/his physician may charge.
Name of Patient
Date of Birth (Day/Month/Year)
Address
TownProvince
*
- I hereby authorize the release to Surgical Tourism Canada any information or records relevant to the condition for which I am seeking treatment through STC.
Physician Statement
When did the symptoms first appear? (Day/Month/Year)
When was the condition first diagnosed? (Day/Month/Year)
Has the patient been placed on a surgical waitlist?
When is your anticipated month/year of surgery?
Have any further complications developed since the condition was diagnosed?
If yes, please explain the complications
Symptoms
Please attach any copies of reports or diagnostic tests pertaining to the condition being treated.
Please list co-morbidity condition(s)
The patient initiated request for travel
The patient of her/his own volition having chosen to receive elective surgery in India or the US and will need to travel there by plane over a two-day period. All travel has inherent risk of delays or accidents in transit, pain or discomfort upon movement, and limited medical capacity of transportation units that may limit available care in the event of a crisis. Please provide your opinion about the suitability of patient’s condition for taking on such travel.
There is no reasonable likelihood of deterioration from or during travel to India.
The patient may be at risk of deteriorating from or during travel. Please explain
*
- Based upon my examination of the patient and the information available to me at the time of examination, I certify that the risks of travel are outweighed by the benefits reasonably anticipated from proper care at the receiving facility.
Physician’s Name
Phone
Address
TownProvince
Todays Date
MD Certified Specialist
Please Specify

Attending Physician’s Statement

Patient Consent

Physician Statement

The patient initiated request for travel