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EDWARD Hospital and Health Services


Medical Opinion Request Form

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This request form is for those seeking a second, or a primary/first, medical opinion. It will take less than five minutes to fill out and will be directed to an Oncology Nurse Navigator. You'll answer basic demographic questions and provide information on your diagnosis or problem. Our Oncology Nurse Navigator will connect with you through your preferred method of communications ? email or phone call ? to discuss your request.

If appropriate, the Navigator will schedule an expedited, in-person physician consult at Edward Cancer Center in Naperville or Plainfield to provide your second opinion including an individualized care plan. Many insurance plans cover second opinions; please contact your insurer.

* Indicates required information
First Name *
Last Name *
Email Address *
Home Phone *
Mobile phone
Street Address 1 *
Street Address 2
City *
State *
Zip *
Country
Year of Birth
Gender *

Please explain your diagnosis or problem. *
Please provide the name of the hospital and provider that provided the initial diagnosis or treatment. *
Please provide any additional information that would be helpful in evaluating your medical opinion request. (Response optional).
How do you prefer to be contacted? *


If Other, please specify:

How did you hear about the Second Opinion Clinic? *




If Other, please specify:

What is the best time of day to receive a call back? *



 

(630) 527-3000

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Edward Hospital & Health Services
801 S. Washington, Naperville, IL 60540 • (630) 527-3000

Naperville • Plainfield • Bolingbrook • Oswego • Woodridge
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