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Patient information
Reason for consultation

RED FLAGS (Please refer patient directly to the closest Emergency!): • Possible Cauda Equina Syndrome • Loss of anal sphincter tone/ fecal incontinence • Saddle anaesthesia about anus, perineum, or genitals • Urinary retention with overflow incontinence • Progressive neurologic deficit • Significant traumaRED FLAGS (Please refer patient to his family doctor !): •Constitutional symptoms (fever, chills) • Unexplained weight loss • Night sweats • History of cancer • Pain worsening at night or at rest • Immunosuppression • IV drug use • Recent bacterial infection

Clinical information (medication, comorbidities, etc.)
Referring doctor
Relevant document(s) (e.g. imaging)

If you are missing information to submit this form, please contact us at 1 (844) 675-2947 / (438) 815-1936 (Mtl).


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