Registration form - Second Opinion

  Personal data of Sender:
  Name:
  First name:
  Title:
  Address:
  phone:
  fax:
  e-mail:
 

 

 
  At this initial phase, I prefer to keep the identity of my relative anonymous.
  Optional personal data of your relative:
  Name:
  First name:
  Title:
  Address:
  phone:
  fax:
  e-mail:
 

 

 

Compulsory data of your relative for initial evaluation procedure:
  Age:  
  Sex: f m  
     
 

Previous diseases of your relative:

Year: Diagnosis (Operation)
     
     
  Please indicate the topic of your request by selecting an item:
  I request:  
  Evaluation of a diagnosis
  Evaluation of a proposed treatment plan and of existing alternatives
  Other
 

 

Describe the development of the disease until now in a few sentences:


 
 

 

Do you know the diagnosis of the disease which is the subject of your request?
If yes, please write it into the box below:


  
 

 

Describe the course of diagnosis and treatment until now:

  
 

 

What is your reason for requesting a second opinion (what should the expert report be about?):


 
 

 

Space for asking further questions to be answered in the expert report:

  

In case you can not send this form, please give us a call at (212)509-0072
Home Contact     Back >