Medical Consultation

Objectives
• What to ask treating doctor
• Second opinion
• Advice about further medical course of action

Name(*)

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Phone No.(*)

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Email(*)

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Location (*)

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Urgency (lowest to highest) - 1 to 5(*)

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Current Problem(*)

Please provide some details of current problem

How long since the problem started/persisted(*)

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Related medical history, if any

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Upload Prescriptions / Reports (optional)

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Captcha(*)

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