Robotic Surgery Consult Form

 

Robotic Surgery Consult Request Form:

Find out if you’re a candidate for robotic prostatectomy at Columbia St. Mary’s. Please provide the following information. The more information you include, the better we will be able to discuss your personal case. You will be contacted by one of our surgeons within three business days.

You may also call for a physician referral by calling (414) 964-7600.

 

* Asterisk indicates a required field.

 

* First name:
* Last name:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Secondary Phone:
* Email Address:
* Date of Birth:
Height:
Weight:
Waist measurement:
Last PSA level:
Biopsy Gleason Score:
Date of Biopsy:
Number of cores taken:
Number of cores positive:
Number of previous abdominal surgeries:
List other medical problems: Heart Attack
Kidney Failure
Diabetes
Other:
Your Health Insurance:
Primary Care Physician:
Primary Urologist:

 

 

* Asterisk indicates a required field.

 

* First name:
* Last name:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Secondary Phone:
* Email Address:
* Date of Birth:
Height:
Weight:
Waist measurement:
Last PSA level:
Biopsy Gleason Score:
Date of Biopsy:
Number of cores taken:
Number of cores positive:
Number of previous abdominal surgeries:
List other medical problems: Heart Attack
Kidney Failure
Diabetes
Other:
Your Health Insurance:
Primary Care Physician:
Primary Urologist:

 

 

* Asterisk indicates a required field.

 

* First name:
* Last name:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Secondary Phone:
* Email Address:
* Date of Birth:
Height:
Weight:
Waist measurement:
Last PSA level:
Biopsy Gleason Score:
Date of Biopsy:
Number of cores taken:
Number of cores positive:
Number of previous abdominal surgeries:
List other medical problems: Heart Attack
Kidney Failure
Diabetes
Other:
Your Health Insurance:
Primary Care Physician:
Primary Urologist:

 

 

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