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Intake

At Whitby Plastic Surgery, we believe in making your journey comfortable. Our team is here to guide you through every step of the intake process, ensuring you feel supported and informed. Let’s explore your options together and find the best treatment for you.

Patient Health Questionaire

Legal First Name

Legal Last Name

Date of Birth

Preferred First Name/Pronouns (if applicable)

Address

City

State/Province/Region

Country

ZIP/Postal Code

Phone

Message

Consent

Do you consent to receive emails from our office?

Height

Weight

Family Doctor or Nurse Practitioner (If no primary care provider, please type "none" in the box)(Required)

Do you smoke? If so, how much per day? If no type NA in the box.(Required)

Medications (prescription and non-prescription)(Required)

Blood thinners, Ozempic, Other (If other, specify in box to the right), No

Medications (Other)

Surgical history: (If none, type NA in the box)(Required)

Medical conditions: (If none, type NA in the box)(Required)

Allergies(Required)

Latex/Rubber Other (If other, specify in box to the right) No

Allergies (Other)

How did you hear about us?(Required)

Doctor’s referral Social media Google Ads Word of Mouth Other, If other specify in the box to the right.

How did you hear about us? (Other)

Address

Jerry Coughlan Health & Wellness Centre,
1690 Dersan St Suite 250 2nd floor,
Pickering, ON L1X 0E3

Phone

1-905-231-0888

Office Hours

Socials

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The information contained on this website is intender for a Canadian audience noted. Information regarding cosmetic services is provided by the American Society of Plastic Surgeons as stock and accordingly prices are in American dollars. This website is designed to provide general information. Results from treatment and services are never guaranteed and may vary. Risk are inherent to any surgical or non surgical treatment and should be discussed in detail with your provider.