2021 New Patient Form: thesecondopinion

thesecondopinion: NEW PATIENT FORM

Please fill out the following forms to be considered for thesecondopinion's free, comprehensive second opinion service. thesecondopinion is a registered 501 (c) 3 nonprofit. mail@thesecondopinion.org. 415-775-9945 Ph. 415-346-8652 Fx.
This is a HIPPA compliant form. Your sensitive patient data is protected by the highest security and encryption standards.

The following paperwork allows thesecondopinion to request your pertinent medical records for our Volunteer Physicians to review your case.

thesecondopinion appointments do not include a physical exam, they are a face to face ZOOM meeting with our Volunteer cancer doctor specialists to go over the details and questions you may have about your diagnosis and treatment. Our Panel usually includes a Medical Oncologist, Radiation Oncologist, Pathologist, Radiologist, and any other sub-specialists indicated.
PATIENT CONTACT INFORMATION
Patient Name:*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Gender (please select)*
Patient Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
California County (please select)
Home Phone Number*

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Best Email address *
Additional Email address
example@example.com
If you are completing this form on behalf of the patient:
Name of Contact

First NameLast Name
Relationship to Patient
If you will be representing the patient, do you have power of attorney?

yesno
Daytime phone number

Area CodePhone Number
Email address
example@example.com
Patient requests assistance in communication (speech impaired, hearing, language translation requested)
Interpreter of which language is requested?
If you have been working with a social worker or Patient Navigator, please list their contact information in the event that we need their assistance. (name, phone, email)
PATIENT HEALTH HISTORY
Cancer diagnosis for which patient seeks a 2nd opinion : (please choose from menu below)*
If your cancer is not listed in the above menu, please describe what you know about your cancer below:
Approximate Date of Original Diagnosis*
If recurrence what is the approximate date of current recurrence:
Please tell us why you are seeking a 2nd opinion.*
Please list 4 questions you would like the thesecondopinion physicians to answer.*
What treatment have you had for this cancer to date? This information helps us determine the medical records needed for your review.*

0/250
Please let us know of any potential important upcoming procedures, surgeries, tests, doctor visits, genetic testing results, etc. *

0/250
Have you already received a 2nd opinion for this cancer? If so, where? Do you have the reports or summary of the suggestions?

0/250
Do you authorize thesecondopinion to use secure email with staff, medical director, and Physician Volunteers when distributing your records?*

yesno

thesecondopinion: PATIENT HEALTH RELEASE FORM - Part A.

1200 Gough Street, #500, SF, CA 94109 : PH: 415-775-9956 FX:415-346-8652 : mail@thesecondopinion.org
Patient Name*

First NameMiddle NameLast Name
Patient's Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Patient Medical Record Number, if applicable:
I HEREBY AUTHORIZE THE FACILITY/DOCTOR LISTED BELOW TO RELEASE MY PERTINENT MEDICAL RECORDS TO thesecondopinion: Howard B. Kleckner,M.D. thesecondopinion, 1200 Gough St. # 500, San Francisco, CA. 94109. PH: 415-775-9956, CELL: 510-609-2393, FX: 415-346-8652 mail@thesecondopinion.org
Name of Hospital Facility/Location of Patient Medical records*

NAME OF FACILITY, HOSPITAL or PHYSICIAN

Street Address

CityState / Province

Postal / Zip Code
MEDICAL RECORDS TO BE RELEASED TO thesecondopinion :
INTENDED USE of MEDICAL RECORDS: Second Opinion Cancer Consultative Tumor Panel, thesecondopinion. DURATION: I understand that this authorization is effective immediately and shall be valid for one year. RIGHT TO REVOKE: I understand that I may revoke this authorization in writing at any time. I understand no other use will be made of this information without my prior authorization unless such use is required by law.
Patient Signature (you may use your mouse or trackpad.*

Clear
Date

MonthDayYear
Date

Physicians and Medical Records

To the best of your knowlege, please list all physicians and medical facilities involved in your care. Addresses, date ranges and phone numbers and fax numbers are appreciated.
Please List the Main Hospital, Facility your pertinent medical records can be found. (ie. UCSF, Kaiser San Diego, Etc.)*

Main Hospital or Facility (Kaiser, Stanford, Sutter, etc.)

Street Address

CityState / Province

Postal / Zip Code
Name of your medical Oncologist:
Dates under care with above Oncologist:
Oncologist Office Phone Number

Area CodePhone Number
Oncologist Office Fax Number

Area CodePhone Number
Oncologist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Surgeon (if applicable)
Dates under care with above Surgeon:
Surgeon Office Phone Number

Area CodePhone Number
Surgeon Office Fax Number

Area CodePhone Number
Surgeon Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Radiation Oncologist (if applicable):
Dates under care with above Radiation Oncologist:
Radiation Oncologist Phone Number

Area CodePhone Number
Radiation Oncologist Fax Number

Area CodePhone Number
Radiation Oncologist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Other Specialist not listed above: (ie. Internist, Urologist, Gynecological Oncologist, etc.)
Type of specialist (Urologist, Gynecological Oncologist, Pulmonologist, Radiologist, etc.)
Dates under care with above specialist physician:
Specialist Office Phone Number

Area CodePhone Number
Specialist Fax Number

Area CodePhone Number
Specialist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Thank you for completing thesecondopinion's New Patient Form

Please Click SUBMIT FORM below.
If you have further questions, type them below or send us an email at mail@thesecondopinion.org or call 415-775-9956
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thesecondopinion: NEW PATIENT FORM

PATIENT CONTACT INFORMATION

PATIENT HEALTH HISTORY

thesecondopinion: PATIENT HEALTH RELEASE FORM - Part A.

Thank you for completing thesecondopinion's New Patient Form