Second Opinion Report

Date: {dateOfRequest}

Case Reference #: {caseReference}

Patient Name: {patientName}

Patient Date of Birth: {patientBirthdate}

Patient Address: {patientAddress}

Physician's name: {providerName}, {providerTitle}

Department: {consultationType}

Speciality: {consultationType}

Reason for Consultation: 

{description}

Summary of Clinical Data / Treatment Summary: 

{summaryTreatment}

Question 1 (asked by patient):  {question1}

Doctor Response:

{question1Ans}

Question 2 (asked by patient):  {question2}

Doctor Response:

{question2Ans}

Question 3 (asked by patient):  {question3}

Doctor Response:

{question3Ans}

Second Opinion Recommendations: 

{recommendations}

Doctor Name: {providerName}

Doctor Signature:  {providerSignature}

The above report was prepared from review of all the information and materials provided by the patient or patient representative to the expert physician for the purpose of second opinion. The above report was provided by the signing physicians at the request of the referring physician, patient or patient representative as a second opinion. The opinions and recommendations included therein are provided on a strict advisory basis and are based on the images and clinical information provided. Neither the expert physician nor the company assume responsibility for any decisions made or actions taken or lack of actions based on this report nor for any effects that result from such decisions and actions. The expert physician does not establish a doctor-patient relationship through review of images and clinical information and creating this second opinion report. The responsibility for clinical decisions remains entirely upon the patient’s treating medical team. This information has been clearly communicated at the time of request of this second opinion. Doctors electronic signatures are valid as if he/she signed in person.