Obțineți a doua opinie

Patient's Name/Surname*

Gender*

Female

Male

Divers

Date of birth*

Telephone number*

Email*

Country and city of residency*

Current diagnosis

Your question

Upload your medical reports (no image files)

Radiological images

You can also upload your radiological images directly into our hospital’s system. We will send you the correspondent link upon request. Additional medical reports can also be send at: telemedicine-ims@uniklinik-freiburg.de

Authorization for third parties*

yes

Authorization for third parties*

I want to use encrypted E-Mail communication (registration required)*

yes

Rules and prices*

I have read the information about the rules and prices for the second-opinion services as well as the Terms and Conditions and accept them.

I have read the Privacy Policy and agree to the following Collection of Personal Data Policy¹

These declarations of consent are given voluntarily and I may withdraw them at any time. The legality of the data processing shall remain unaffected unless it is withdrawn.

How did you find our hospital?

Internet

friends/ relatives/ previous patients

your physician

newspaper/magazine

exhibition

social media/ forum

other**

How did you find our hospital?*

Please note: according to the German law, your physician must be present during your online-consultation

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Second Opinion Request Form