This form is used to request an opinion on superior rectal artery embolization (Emborrhoid) for bleeding internal haemorrhoids, when office treatments have failed or surgery is undesirable. A haemorrhoidal origin of the bleeding must be confirmed (proctology opinion, colonoscopy depending on age and symptoms).

Before sending your request:

see a proctologist to confirm that the bleeding comes from haemorrhoids;
attach the colonoscopy report if one was done (recommended depending on age and symptoms);
list the treatments already tried (venotonics, rubber band ligation, sclerotherapy, surgery).

📀 CT or MRI images: download link (recommended)

Please do not attach the images to the form or send photos of them: we need the original images (DICOM format), shared via a link.

How do I get this link?

Your imaging centre gave you a link or an access code to view your images online: paste the link into the field above and give any access code in your message.
You have a CD or a USB stick: copy its entire content to your computer (the complete folder, including the DICOMDIR file), without renaming or sorting anything.
Go to wetransfer.com, click the three dots (…) and choose to send as a link: no e-mail address is needed. Add the folder, start the transfer, then copy the link into the field above.
A free WeTransfer link is only valid for 3 days: send this form as soon as the link is created. You can also use SwissTransfer (free), whose link can stay valid for up to 30 days (choose the longest duration).

If you cannot do this, send the form without the images: we will tell you how to send them if they are needed.

Examination report (one PDF or photo, 10 MB max; images go through the link above)

Last name (required)

First name (required)

Phone number (required)

Email (required)

Date of birth (required)

Postal address (required)

Patient ID number (IPP) (optional, if known)

I have a referral letter (from my GP or specialist)

Attach the referral letter (one PDF or image, 10 MB max)

Useful information to assess your file

You are (optional)

Main symptom (required)

Proctology opinion and colonoscopy (required)

Haemorrhoid grade (if known) (optional)

Anaemia related to the bleeding? (optional)

Treatments already tried (optional)

Do you take anticoagulant or antiplatelet medication? (optional)

Your message (optional)

Your identity and contact details are needed to process your request and get back to you.

After submitting, you will be taken to a confirmation page in French: this is expected. We will get back to you by email, in English if you prefer.