GNI Second Opinion Form

Second Opinion Questionnaire

Please answer the questions as best as you can below to better assist you *If you have any acute or life-threatening symptoms or concerns, please call 9-1-1 or go to your nearest ER, do not use this form
Full Name *

First Name Last Name
Phone Number *
Email
example@example.com
How would you like us to reach you
What region are you in?
What is your Gender? *

Male Female Prefer Not to Say Non-Binary
What is your age?
What condition you would like us to evaluate for a second opinion? *

Acoustic neuroma Brain Aneurysm Arteriovenous malformations (AVMs) Brain tumor Cerebrovascular surgery/vascular problems Carotid artery disease/stenosis Deep brain stimulation (DBS) Neurologic ailment (dizziness, headaches, vertigo, etc) Pituitary tumors Seizures/Epilepsy Spine conditions Spinal cord tumors Spine tumor
Tell us about your symptoms you're current experiencing
Are you currently under the care of a Neurologist or Neurosugeon? *

Yes No
Have you had any recent procedure or surgery? *

Yes No
If yes, please explain
Upload any supporting documentation you'd like us to review

Browse Files
Medical documentation, treatment course, physician or provider notes Cancel of
Click here upload images to our secure portal and complete your second opinion request.

GNI Ambra Secure PACS Portal for Second Opinion

Second Opinion Questionnaire