For Healthcare Professionals For the Media Careers
Henry Ford Health System
1 (800) 436-7936

Request an Online Kidney Surgery Consult

If you have a kidney tumor 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
Name * 
Street Address  * 
City * 
State * 
Zip/Postal Code * 
Email Address * 
Date of Birth * 
Approximate size of kidney tumor 
Side of tumor (right or left kidney) 
Evidence of spread of tumor outside the kidney? 
Do you have images that you can send to us?
Please mail your images, either digital or in traditional film format, to:
Henry Ford Hospital, Vattikuti Urology Institute,
2799 W. Grand Blvd., Detroit, MI 48202 
Serum creatinine level 
Previous kidney surgery? 
Previous Abdominal Surgery  
Other Medical Problems  

If Other, please specify:

Your Health Insurance 
Name of Primary Care Physician  
Zip/Postal Code 
Office Phone 
Office Fax 
Name of Primary Urologist  
Office Phone 
Office Fax