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Henry Ford Urology Consult Request Form

If you have prostate cancer and think that you may be a candidate for robotic surgery, our team of specialists is prepared to help you. Please fill out this form and we will contact you within 24 hours to discuss your case. The more completely this form is filled out the better we can discuss your case.
* Indicates required information
First Name *
Last Name *
Address *
City *
State *
Zip/Postal Code *
Home Phone *
Other Phone *
Email Address *
Date of Birth *
Height *
Weight *
Waist Circumference *
PSA *
Biopsy Gleason Score *
Date of Biopsy *
How many cores taken? *
How many cores positive? *
Previous Abdominal Surgery *
Other Medical Problems *	Stroke MI / Heart Failure Renal Failure Diabetes Other If Other, please specify:
Your Health Insurance
Name of Primary Care Physician *
Address
City
State
Zip
Office Phone
Office Fax
Email
Name of Primary Urologist *
Address
City
State
Zip
Office Phone
Office Fax
Email