Second Opinion Medical Imaging Upload

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  • MEDICAL SECOND OPINION BRAIN TUMOR AND NEURO-ONCOLOGY REQUEST FORM

    I am requesting Culicchia Neurological Clinic to provide a remote second opinion of my condition.

  • I understand that this second opinion is based solely on the materials provided to Culicchia Neurological Clinic, without a physical exam. As such, there are risks and limitations of any medical opinion provided. I agree to provide copies of my medical records and any other relevant diagnostic reports or studies. I also understand as the patient requesting the remote second opinion, only I will receive a copy of the assessment and recommendation and it is my responsibility to forward the report to my treating physician(s) or other providers. I also understand that I will be provided with a second opinion only and that this request will create no physician-patient relationship with any physician at Culicchia Neurological Clinic.