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Collaborative questionnaire:

Are you currently waiting for a consultation?
 Yes
 No

If so, how long have you been waiting?
 Less than 6 months
 6-12 months
 12-18 months
 18-24 months
 More than 24 months

Are you currently waiting for surgery?
 Yes
 No

If so, how is the estimated wait time for your consultation to surgery?
 Less than 6 months
 6-12 months
 12-18 months
 18-24 months
 More than 24 months

What breast option(s) are you waiting for?
 Back Flap
 Free Flap (Abdominal)
 Free Flap (Other)
 Implants
 Pedicled Flap

What region in Canada are you from?

Where would you be open to receive care? Click all applicable:
 Close to home
 In my region
 In my province
 In another province

Can we contact you via e-mail to discuss breast reconstructive surgery?
 Yes
 No

Your e-mail address: