Radiology Experts | Specialist Second Opinions

Patient Demographics

First Name *Last Name *Date of Birth *Health Card Number (HCN) *Phone NumberEmail Address

Provider First Name *Provider Last Name *Billing / MSP Number *Required for verificationClinic Name

Report Delivery Preferences *

Fax ReportSecure Email

Fax Number *

Priority Level *

Urgent< 24 hoursSemi-Urgent48 hoursRoutine5-7 days

Reason for Referral / Clinical History *Imaging Info (Optional)Upload Reports & Imaging (Optional)

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