Get Consultation Request Form

Filling out the Consultation Request Form online is a straightforward process that ensures clear communication between healthcare providers. This guide will walk you through each section of the form to facilitate a smooth submission for a second opinion from the Johns Hopkins Department of Neurology.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the Consultation Request Form and open it in your preferred editor.
2. Enter the name of the patient in the designated field provided.
3. Ensure that you acknowledge the request for a remote second opinion by confirming that both you and the patient have discussed this and understand the associated risks.
4. Provide a statement indicating the commitment to share the patient's medical records and relevant diagnostic reports.
5. Complete the acknowledgment that you are a licensed physician in the relevant states.
6. Sign the form in the designated signature field and input the date.
7. Fill in your name as the treating or referring physician along with the name of your practice.
8. Provide the complete street address, including suite information, city, state, and zip code.
9. Input your office phone and fax numbers.
10. Review all the entered information for accuracy. Once confirmed, save your changes, and then choose to download, print, or share the completed form as needed.

Complete the Consultation Request Form online to ensure timely receipt of your second opinion.