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Address
What is the best email(s) for us to communicate with you?
For this type of surgery we need to know your height and weight.

Medical History

Do you have any health problems other than the pilonidal issue?
It is important that we know the name of any previous operations you've had, particularly if any involved a flap, such as a Limberg, Gluteal, or Rhomboid flap, a V-Y Plasty or Z Plasty, or a previous cleft lift.
What are your current symptoms? How has the pilonidal disease been bothering you?
Please list all medication allergies or any medications to which you have had side effects. If you are unable to swallow pills, let us know.

Some specific medical questions:

Please answer each of these important questions. If they don't apply to you just answer "none" or "N/A".
Have ever had any bleeding problems with surgery, or any known coagulation disorder?
Have you ever been diagnosed with MRSA (Methicillin Resistant Staph Aureus), or any other antibiotic resistant bacteria?
Do you have any dermatologic problems, such as hidradenitis suppuritiva (HS), psoriasis, eczema, acne, etc.? If so, please tell us about them.
Do you have any other medical problems or diagnoses that you haven't mentioned? If so, please tell us about them.
Do you have diabetes, and if so, do you use an insulin pump for diabetes?
Have ever been diagnosed with any type of autoimmune disease? If so, which diseases and how are they being treated? Examples would be psoriasis, hidradenitis suppuritiva, lupus, thyroiditis, Crohn's disease, etc.
Are you taking any immune suppressants, like prednisone or other steroids; or any biologics such as Humera, Enbrel, Remicade, Orencia, Rituxan, Plaquenil Cosentyx or any medication for an autoimmune disease?
This is where you attach photos to this form.
The Photos need to be current, and show the up-to-date appearance of the wound.  WE MUST HAVE THE EXACT PHOTOS SHOWN IN THE LINK.  (follow this link for examples on the photos needed -  https://pilonidal.com/photos/)  If you decide to send photos from any previous operations, please label them with the date of the photo and a history.
Click or drag files to this area to upload. You can upload up to 10 files.

DON'T FORGET TO HIT THE SUBMIT BUTTON WHEN YOU ARE FINISHED.

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