BANFF PLASTIC SURGERY
403-762-2055

How may we assist you?

The firsts step to arranging an appointment is to complete our patient registration form (we cannot schedule an appointment without having this form completed first).

If the form fails to submit, there is most likely an errant entry in the form that needs to be corrected. Please review for any highlighted mistakes and resubmit.

When the form is received in our office, the nurses will review your medical history and contact you if clarification or additional information is required. Otherwise, you will be contacted by one of our receptionists who schedule all consultation appointments. We do charge a consultation fee of $105.00 tax inclusive.


How would you prefer to be addressed:

Would you like to receive our newsletter?* Yes, I'd like to join Banff Plastic Surgery's mailing listNo, I wouldn't like to join Banff Plastic Surgery's mailing list

Mailing Address *

Cell Phone *
Home Phone

May we leave a message?
YesNo

Business Phone

May we call this number?
YesNo

Date of Birth: *
Marital Status: *

Emergency Contact (EC) *
Relationship to EC *
EC's Phone *

Assign Designate *
Do you authorize Banff Plastic Surgery to speak with a designate on your behalf, which may include detailed information?
YesNo

Who? *

Relationship? *

Patient's Health Care Number *
Province *
Patient's Name on Health Care Card *

Expiry Date, If Applicable:
Referring Doctor

Family Physician *
Please provide first and last name, address and phone number:

Family Physician Communication *
We normally like to communicate with your Family Physician about your care. Is this all right with you?
YesI prefer to keep my visit confidential.

Your Occupation *

How did you hear about us? *
Magazine adTelevision adFacebookMy friend told me about Dr. Hall-Findlay.My friend told me about Dr. MacLennan.My Doctor told me about Dr. Hall-Findlay.My Doctor told me about Dr. MacLennan.Your location for surgery/care (resort location of Banff) is appealing to me.I was looking for a fellow/board certified plastic surgeon.I heard Dr. Hall-Findlay speak.I heard Dr. MacLennan speak.I read an article about Dr. Hall-Findlay.I read an article about Dr. MacLennan.Banff Plastic Surgery WebsiteRealSelf.comRatemds.comWhatclinic.comOther Patient Review WebsiteOther WebsiteSearch EngineYouTubePrevious Patient

Are you available for a consult appointment with 7 days or less notice? *
YesNo

Have you lost weight?
YesNo

How Much? *

Bra Size

Have you ever had a heart attack or heart trouble?
YesNo

Type of Test? *

Where was the test completed? *

When was the test completed? *

Do you have a heart murmur?
YesNo

Type of Test? *

Where was the test completed? *

When was the test completed? *

Do you need antibiotics before surgery and dental procedures? *

Did you have rheumatic fever as a child?
YesNo

How old were you? *

Were you hospitalized? *

Please Explain? *

Have you ever had chest pain, angina or chest tightness?
YesNo

Type of Test? *

Where was the test completed? *

When was the test completed? *

Please Explain *

Does climbing one flight of stairs give you chest pain or make you short of breath?
YesNo

Does walking one city block give you chest or leg pain, or make you short of breath?
YesNo

What do you do for exercise?

Have you ever been treated for an abnormal heartbeat?
YesNo

Type of Test? *

Where was the test completed? *

When was the test completed? *

Name of the doctor at the time *

Please Explain *

Do you have high blood pressure?
YesNo

Is it well controlled? *

Have you ever had fluid in your lungs?
YesNo

When? *

Were you ever hospitalized? *

Please Explain *

Do you ever have difficulty with your breathing?
YesNo

Please Explain *

Do you have emphysema/COPD?
YesNo

Please Explain *

Have you ever used an inhaler/puffer?
YesNo

Why *

Do you have asthma or bronchitis?
YesNo

Do you use Ventolin? *

How often? *

Reason for use: *

Do you have difficulty breathing at night or in the early morning?
YesNo

Have you been hospitalized due to an asthma attack or bronchitis? Please Explain. *

Have you visited an ER due to an asthma attack or bronchitis? Please Explain. *

Any recent problems with asthma or bronchitis? *

With any previous surgeries were there any concerns with your asthma or bronchitis? Please explain. *

Do you have sleep apnea/periods of non-breathing during sleep?
YesNo

Type of Test *

Where was the test completed? *

When was the test completed *

Name of the doctor at the time *

Do you need a CPAP or any other device to help you sleep? *

Do you snore loudly enough to be heard through closed doors?

Do you often feel tired, fatigued, or sleepy during the daytime?

Has anyone observed you stop breathing during your sleep?
YesNo

Do you now smoke any forms of tobacco?
YesNo

How many cigarettes per day? *

How long have been smoking? *

Do you have a chronic cough? *

Is your cough dry or wet (productive)? *

Do you have a history of chest infections and treatments?
YesNo

Please Explain.*

Do you use any recreational "street" drugs?*
YesNo

Please explain *

Do you have liver disease, or a history of jaundice or hepatitis?
YesNo

Type of Test *

Where was the test completed? *

When was the test completed? *

Name of the doctor at the time *

If you have hepatitis, please indicate which type *

Do you drink more than three drinks of alcohol per day?
YesNo

Do you have indigestion, heartburn, hiatus hernia, or ulcers?
YesNo

How often? *

Do you take any medication for it? *

Please explain: *

Do you have kidney problems?
YesNo

Please explain: *

Do you have a history of thyroid problems?
YesNo

Type of Test *

Where was the test completed? *

When was the test completed? *

Name of the doctor at the time *

Is it well controlled? *

How often is it monitored? *

Do you have diabetes?
YesNo

Is it well controlled? *

How is it controlled (diet/medications)? *

How often is it monitored? *

Have you ever had a stroke?
YesNo

Please explain: *

Do you have epilepsy, blackouts, or seizures?
YesNo

How is it controlled? *

Have you seen any specialists? *

Have you donated blood in the past 6 months?
YesNo

When did you donate? *

Have you been in any major accidents?
YesNo

Accident History *

Have you or a member of your family ever had blood clots, excessive bleeding, deep vein thrombosis or pulmonary embolus?
YesNo

Who had the concern?

Which bleeding concern did they have?

When did it happen?

Was there testing involved?

What treatment was involved?

Have you ever had a spinal?
YesNo

Any concerns?

Have you ever had an epidural?
YesNo

Any concerns?

Have you ever had conscious sedation?
YesNo

Any concerns?

Have you ever had a general anesthetic?
YesNo

How were you waking up?

Please list ALL Surgery History (Procedure AND Year AND Location)*:

Have you or any member of your family had a reaction to anesthetic?
YesNo

Please explain who, the reaction and any relevant details:

Have you experienced nausea and vomiting after a surgery?
YesNo

During which surgery(ies) did you have nausea and vomiting?

How would you rate your nausea and vomiting?

Have you ever had a surgery without nausea and vomiting?
YesNo

Where was it?

When was it?

What procedure?

Are you prone to motion or car sickness?
YesNo

Do you have arthritis, pain, or trouble with movement in your neck or jaw?
YesNo

Please explain:

Any limits to your jaw opening?*

Any limits to your neck movement or extension?*

Have you taken prednisone, steroid medications, or cortisone-like drugs in the past year?
YesNo

Please explain:

Please list any medication allergies (rash, face, neck swelling, itching)*:

Please list any food or medication sensitivities (upset stomach, nausea)*:

Please list any medications, including pills, inhalers and patches or herbal prescriptions you are currently taking (prescription or over the counter) and their dosage (including birth control)*:

Please list any herbals, vitamins, natural supplements or additives that you are currently taking*:

Do you think you may be pregnant?
YesNo

Do you have children?
YesNo

How many?

Type of delivery:

Any problems?

Dates:

Do you plan on having children in the future?
YesNo

Did you breastfeed?
YesNo

When did you stop breastfeeding?

Have you ever had a mammogram?
YesNo

When was the last one?

Where was it done (Clinic and Location)?

What were the results?

Have you ever noticed any breast lumps?
YesNo

Have you had a breast biopsy? (Please indicate which breast)

Have you had an excision? (Please indicate which breast)

What were the results?

Where and when were the procedures done?

Has any first or second degree relatives on your mother's or father's side had breast cancer?
YesNo

Who?

At what age?

Additional info:

Please indicate any other medical problems you have or have had in the past.
Heart DiseaseLiver DiseaseAIDS/HIVArthritisAutoimmune DisorderNerve DiseasePhlebitisSkin DiseasePsychiatric ProblemsBleeding ProblemsCancerFibromyalgiaDiabetesMultiple SclerosisDepressionAnxiety DisorderPacemaker

Exercise Stress Test (Treadmill)
YesNo

When was the test completed?

Where was the test completed?

What was the result?

Nuclear Medicine Heart Scan (MIBI) test
YesNo

When was the test completed?

Where was the test completed?

What was the result?

Heart Catheterization (angiogram)
YesNo

When was the test completed?

Where was the test completed?

What was the results?

Heart Echo (ultrasound) test
YesNo

When was the test completed?

Where was the test completed?

What was the result?

Holter Monitor
YesNo

When was the test completed?

Where was the test completed?

What was the result?

EKG
YesNo

When was the test completed?

Where was the test completed?

What was the result?

Lung Function Test/Pulmonary Function Test
YesNo

When was the test completed?

Where was the test completed?

Cardiologist
YesNo

Visit date

Doctor's name

Location

Reason

Respirologist
YesNo

Visit date

Doctor's name

Location

Reason

Neurologist
YesNo

Visit date

Doctor's name

Location

Reason

Other Specialty
YesNo

What Specialty?

Visit Date

Doctor's Name

Location

Please elaborate

Is there anything else I should know about your medical/obstetrical/surgical or psychiatric history?

Things I Would Like to Talk About
Breast Enlargement (Augmentation)Breast ReductionBreast Uplift (Mastopexy)Corrective Breast SurgeryContour Correction - Abdominoplasty (Tummy Tuck)Remove Existing Breast ImplantsReplace Existing Breast ImplantsInverted NipplesBreast Reconstruction (breast cancer patients)LabiaplastyLiposuctionCoolSculpting

Please Explain

Any comments?


Would you like to receive our newsletter? YesNo

Mailing Address *

Preferred time for Contact *

Do you have any special instructions to protect your privacy (confidentiality)?*

Date of Birth: *

Emergency Contact (EC) *
Relationship to EC *
EC's Phone *

Assign Designate *
Do you authorize Banff Plastic Surgery to speak with a designate on your behalf, which may include detailed information?
YesNo

Who? *

Relationship? *

Patient's Health Care Number *
Province *
Patient's Name on Health Care Card *

Expiry Date, If Applicable:
Referring Doctor

How did you hear about us? *
RealSelf.comFacebookRadio AdTelevision adPrint adMy friend told meMy doctor referred meSearch Engine

Areas you may be interested in treating with Coolsculpting: *
TummyChinThighs (inner or outer)ArmsBack rolls

Height *
Unit
Feet/InchesCentimeters

Weight *
Unit
PoundsKilos

Known sensitivity to cold such as cold urticaria (hives triggered by cold), Raynaud's disease (disorder in which cold leads to reduced blood flow in the fingers, which appear white, red, or blue), pernio or Chilblains (itchy and/or tender red or purple bumps that occur as a reaction to cold)*

YesNo

Poor blood flow in the area(s) to be treated*
YesNo

Neuropathic (nerve) disorders such as post-herpetic neuralgia or diabetic neuropathy*
YesNo

Impaired skin sensation*
YesNo

Open or infected wounds in the area(s) to be treated*
YesNo

Bleeding disorders or use of blood thinners*
YesNo

Recent surgery or scar tissue in the area to be treated*
YesNo

A hernia or history of hernia in the area to be treated or adjacent to treatment site(s)*
YesNo

Skin conditions such as eczema, dermatitis, or rashes in the area(s) to be treated*
YesNo

Pregnancy or lactation (making breast milk or breast feeding)*
YesNo

Any active implanted devices such as pacemakers and defibrillators*
YesNo

Any major health problems such as liver disease*
YesNo

Any known sensitivity to isopropyl alcohol (rubbing alcohol) or propylene glycol*
YesNo

Any comments?

Are you available for a consult appointment with 7 days or less notice?*
YesNo


Would you like to receive our newsletter? * YesNo

Mailing Address *

Date of Birth: *

Marital Status*

Healthcare # *

Do you currently have a pacemaker or any other implanted devices? *

Are you currently pregnant or lactating? *

Do you have diabetes?

Do you have any skin conditions?

Do you have any open sores, rashes or abrasions currently in the armpits?

Have you ever had surgery in/around the armpit?

Have you ever had local anesthetic?
YesNo

Any concerns? *

Please list any food or medication allergies (rash, face or neck swelling, itching):?

Please list any food or medication sensitivities (upset stomach, nausea);

Please list any medications, including pills, inhalers and patches or herbal preparations you are currently taking?

Your Occupation *

How did you hear about us? *
Please check all statements that apply.
**All information given will remain confidential**
Magazine adTelevision adFacebookMy friend told me about Dr. Hall-Findlay.My friend told me about Dr. MacLennan.My Doctor told me about Dr. Hall-Findlay.My Doctor told me about Dr. MacLennan.Your location for surgery/care (resort location of Banff) is appealing to me.I was looking for a fellow/board certified plastic surgeon.I heard Dr. Hall-Findlay speak.I heard Dr. MacLennan speak.I read an article about Dr. Hall-Findlay.I read an article about Dr. MacLennan.Banff Plastic Surgery WebsiteRealSelf.comRatemds.comWhatclinic.comOther Patient Review WebsiteOther WebsiteSearch EngineYouTubePrevious Patient

Are you available for a consult appointment with 7 days or less notice?*
YesNo