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Order form: Second medical opinion

Specialist:

Please note that, this is a non-binding request. Your request first needs to be reviewed and confirmed by our support team.

E-mail

Confirm e-mail

Customer code

I confirm that the person requesting the service is the same as the one listed in the contract.

Describe your health problem

Briefly describe the health problem you want to get a second medical opinion on. You'll be able to add more details later.

Questions for the specialist

Indicate the questions you would like the specialist to answer.

Available medical documents

Please specify what types of medical records you have available.

I confirm that I have read, consent and agree to Privacy Policy

By clicking on "Confirm" you agree with Terms of use

These services are brought to you by Diagnose.me.

Diagnose.me BV
Dorpsdijk 63
4156AM Rumpt, The Netherlands

www.diagnose.me

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