|State/Province/Territory Licensed In:||_________________________________
I am a physician licensed to practice medicine in the above state, province, or territory. On behalf of my patient, who consents to this request, I am requesting an online medical second opinion consultation from a Cleveland Clinic physician. I understand that the service being provided by the Cleveland Clinic physician is an online medical second opinion consultation only and that my patient will remain under my direct care. I acknowledge that the online medical second opinion consultation report will be sent directly to me at the address I am supplying below.
Physician's Signature: ____________________________________
Form must be printed and signed in ink. E-signatures cannot be accepted.
Physician's Mailing Address:
NOTE TO REQUESTOR: This form is required for all residents outside Ohio and Canadian provinces outside Ontario.
Please include this completed form in the packet of materials that you are sending to Cleveland Clinic.
If you have questions, please contact the Cleveland Clinic MyConsult Office:
|Please note: This form is valid for 365 days from the signature date.|
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