| Physician: | _________________________________ |
| Specialty: | _________________________________ |
| State Licensed In: | _________________________________ |
| Patient Name: | _________________________________ |
I am a physician licensed to practice medicine in the above state. 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: ____________________________________
Date:____________________________________
Physician's Mailing Address:
_________________________________
_________________________________
_________________________________
NOTE TO
REQUESTOR: This form is required for all residents outside of Ohio. Please include this completed form in the packet of materials that
you are sending to The Cleveland Clinic.
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