Medical Opinion
Request Form

Completing this form will take less than five minutes. You'll answer basic demographic questions and provide information on your diagnosis or question. Our nurse navigator will then review your inquiry and possibly consult an oncologist, depending on the nature of your request, to most fully meet your needs. Then the nurse navigator will contact you, usually within one to two business days, to discuss your situation and determine the appropriate next steps.

* Indicates required information
*First Name
*Last Name
*Home Phone
Mobile phone
*Street Address
Street Address 2
Year of Birth

*Please tell us briefly about your diagnosis:
*Please provide the name of the hospital or clinic and provider that offered the initial diagnosis or treatment:
Please provide any additional information that would be helpful in evaluating your medical opinion request:
Best way to reach you:

If Other, please specify:

What is the best time of day to receive a call back?
Elmhurst Memorial Healthcare Network

This site is part of the Elmhurst Memorial Healthcare network of Web sites, which covers a variety of topics using the same philosophy: When it comes to medical care, we know that you have a lot of options. And we want you to know that you're more than a patient to us. You're an individual. We would appreciate the opportunity to provide you with state-of-the-art medical care and down-to-earth, personalized attention.

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