Secure Online da Vinci Consult Request Form

Terms of Use

Please do not use this form to schedule a general appointment with our office.

By agreeing to the terms of our secure forms, you will enter a secure area of our web site. Farjaad Siddiq, MD, FACS will not be held responsible in the event your electronic message is not transmitted due to technical problems related to this site or to the hosting server. All personal identifying information is encrypted and your message will not be internally or externally forwarded to other third parties. The information will solely be used by Farjaad Siddiq, MD, FACS.

Your request will be processed within 24 hours, during normal business hours, excluding holidays. If you do not accept the terms of this disclaimer, you will not be able to process your request on-line.

Referring Physicians

Thank you for referring your patient. Please fill out this form to refer a patient who you feel may be a candidate for da Vinci surgery. We will contact your patient within 24 hours on normal business days to schedule a consultation with our office. The more completely this form is filled out the better we can assess and discuss their case.

Patients

Please complete this form if you believe that you are a candidate for da Vinci surgery or have been referred by your physician. We will contact you within 24 hours to schedule a consultation with our office. The more completely this form is filled out the better we can assess and discuss your case. If you do not hear from our office within that time frame, please contact our office by phone.

If you have any questions regarding the use of these forms, please contact our office during normal business hours.