International Triage - Request Service

Request Service

Request for 2nd Medical Opinion Service

Patient Information


	First	Middle	Last
Full Name
Gender	Male Female
Birthday	(e.g.. 01/01/2006)

Physical Address (Not P.O. BOX)

Street Address		City
State/Province		Zip/Postal Code
Country
Home Phone	(include country and city code)
Daytime Phone	(include country and city code)
Cell Phone	(include country and city code)
Email
Best Contact Mode
Preferred Language		If other please indicate
How did you hear about *International Triage?*

Medical Information

Clinical specialty needed for my 2nd Opinion:
I have been experiencing symptoms for

In your own words describe the reason for seeking a 2nd medical opinion:


Please describe treatment to date by your doctors in connection with the 2nd Opinion Request:


ALLERGIES Please list ANY ALLERGIES you have, including medication allergies:

MEDICAL STATUS List all existing (active) medical conditions (example: if diabetic, list insulin intake. If hypertensive, list your "normal" blood pressure. List all medications by name and dosage.

MEDICAL HISTORY: List previous operations, procedures, conditions for which you were treated.


Contact Information of the Physician Who Is Currently Treating Me

Physician Name
Type		Specialty
E-Mail
Phone		Cellular
Address
City		State/Province
Postal Code		Country


Supporting Information

Kindly send the information below by fax to 305-517-3873 or by E-mail to info@InternationalTriage.com Please include cover sheet with your contact information:

1. Case Summary from your phisician.

2. Results of relevant lab reports.

3. Results of relevant diagnostic imaging.

4. Results of any other relevant tests.

Important Information

Information collected from this request for service, and in subsequent transmittals, will only be used form and in conjunction with, formulating appropriate administrative and medical decisions necessary for responding to this request for service. Unless responded to affirmatively by International-Triage, LLC, the Information provided by the patient does not create any type of relationship between the individual providing the information and participating medical providers of International-Triage, LLC or any physicians, staff, agents and directors, whatsoever. Moreover, an affirmative response does not constitute a provider-patient relationship with International-Triage, LLC whatsoever. This information provided hereto is considered Protected Health Information (PHI) and will be used to contact you because you have requested to be contacted. Non clinical information provided on the website, or in any response to you, is not and cannot be considered medical advice or treatment guidance. 2nd Opinion is a best efforts evaluation of your medical condition based on information provided by, or on behalf of the patient. IT IS NOR MEANT TO BE USED AS TREATMENT GUIDELINES International-Triage, LLC, its subsidiaries, participating medical providers, or any of their entities, physicians, staff, agents and directors will not be held liable for, and you will release and hold them harmless from, any claims and/or any direct, indirect, consequential, special, exemplary, or other damages arising there from, whatsoever. Please consult with your doctor for medical advice or treatment for any condition you may have.

If you are experiencing a medical emergency, call 911 and/or go to the nearest emergency room.
I have read, understood and agree to the above.