GNI Second Opinion Form

Second Opinion Questionnaire

Please answer the questions as best as you can below to better assist you *If you have any acute or life-threatening symptoms or concerns, please call 9-1-1 or go to your nearest ER, do not use this form
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email
example@example.com
How would you like us to reach you
What region are you in?
What is your Gender?*

MaleFemaleNon-BinaryPrefer Not to Say
What is your age?
What condition you would like us to evaluate for a second opinion?*

Acoustic neuromaBrain AneurysmArteriovenous malformations (AVMs)Brain tumorCerebrovascular surgery/vascular problemsCarotid artery disease/stenosisDeep brain stimulation (DBS)Neurologic ailment (dizziness, headaches, vertigo, etc)Pituitary tumorsSeizures/EpilepsySpine conditionsSpinal cord tumorsSpine tumorOther
Tell us about your symptoms you're current experiencing
Are you currently under the care of a Neurologist or Neurosugeon?*

YesNo
Have you had any recent procedure or surgery?*

YesNo
If yes, please explain
Upload any supporting documentation you'd like us to review

Browse Files
Medical documentation, treatment course, physician or provider notes Cancelof
The GNI Second Opinion Program provides informational opinions only to help guide you in seeking additional work-up and/or care. These opinions are not formal medical advice, diagnosis, or treatment recommendations.

Participation in this program does not establish a patient-provider relationship with GNI or its clinicians. Our team’s review is based solely on the records you provide and may not reflect the full clinical picture.

To receive medical care, diagnostic testing, or treatment from GNI, patients must schedule an in-person evaluation with one of our providers.

By submitting your information, you acknowledge that you have read and understand this disclosure.
Please submit form before uploading images in step 2 (below)

Questions? Email secondopinion@gnineuro.org
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Second Opinion Questionnaire

Please submit form before uploading images in step 2 (below)