The Richard T. Johnson Division of Neuroimmunology and Neurological Infections
Remote Second Opinion Program
Forms and Documentation

The following items are needed to provide you with the best assessment and recommendation:

Required Forms

1. Patient Disclaimer
   (authorized signature required)
2. Patient Intake Form
   
3. Consultation Request Form
   (signed by your local physician)
4. Payment Authorization Form
   (authorized signature required)
5. Medical History Questionnaire
   (authorized signature required)

1. MRI Films
   (first ever, diagnostic, and most recent)
2. Office Visit Notes (as appropriate, but
   minimally for the past year)
3. Laboratory Results
   (first ever/diagnostic and most recent)
4. Hospital Discharge Summaries
   (as appropriate, but minimally for the past year)
5. Current Medications and Dosage Information
   (indicate on medical history questionnaire)

• Request a Second Opinion
• Required Forms & Documentation
• Second Opinion Fees
• Terms and Conditions
• Home Page