2nd Medical Opinion Request
Please enter details of the physician, patient and case a 2nd medical opinion is requested for.
Priority
Priority
*
Critical Request/Transfer (Immediately)
Urgent Request < 30min
Standard Request < 4h
For critical cases, please call one of the following emergency numbers directly
now
ARDS:
555-555 111
All other:
555-555 112
Hospital Details
Request Type
*
First request
Follow-up
Requesting Clinician Name
*
First Name
Surname
Telephone Number
*
Email Address
*
example@example.com
Hospital Name
*
ICU / Location
Department
Information/Privacy Regulations - Agreement
Yes
Specialty Details
Specialty
*
ARDS / ECMO
Non-Operative Intensive Care
Operative/Neurologiscal Intensive Care
Pediatric Intensive Care
Patient Details
Patient Name
*
First Name
Surname
Gender
*
male
female
Date of Birth
*
-
Day
-
Month
Year
Health Insurance
Presenting Complaint
Secondary Diagnosis
Main Diagnosis
Power of Attorney / Disposition
Weight
Height
Laboratory Investigation Details
ASAT
U/l
ALAT
U/l
Bili
mg/dl µmol/l
Please Select
mg/dl
µmol/l
Unit
Krea
mg/dl µmol/l
Please Select
mg/dl
µmol/l
Unit
Hst
mg/dl mmol/l
Please Select
mg/dl
mmol/l
Unit
CRP
mg/dl mg/l
Please Select
mg/dl
mg/l
Unit
PCT
ng/ml
Leukocytes
Zellen/nl
Hb
mmol/l g/dl
Please Select
mmol/l
g/dl
Unit
HK
%
TPZ
%
INR
PTT
%
Thrombozyten
Cells/nl
ATIII
%
Diagnostic Details
COVID-19
Yes
COVID-19
-
Day
-
Month
Year
Date
CT
Findings
-
Day
-
Month
Year
Date
Mibi
Findings
Serology
Findings
TTE/TEE
Findings
-
Day
-
Month
Year
Date
Neurology vor ITN
Therapy Details
Bisherige Abx
Aktuelle Abx
CVVH(D) / HD
Diuretic
Balance
Positive
Negative
Balanced
Intubation
Tracheostomy
-
Day
-
Month
Year
Date
Position
Supine Position
Prone Position
135° Position
Lateral Position
Sedation
Glucose
Yes
Relaxation
Yes
Resuscitate?
Yes
Optimization
Ventilation
Positiopn
Balance
Anti-infectives
Cardiovascular Details
Rhythm
Catecholamine therapy
µg/kg/min
Ventilation Details
Mode
Pinsp.
mbar
PEEP
mbar
I:E
Tinsp
s
AF
/ min
AMV
l/min
VT
ml
FiO2
%
Buffering
Please Select
NaBi
TRIS
Unit
Modul BGA
pH
PaCO2
mmHg
PaO2
mmHg
BE
mmol/l
Bicarbonate
mmol/l
Lactate
mmol/l mg/dl
Please Select
mmol/l
mg/dl
Unit
Blood Sugar
mmol/l mg/dl
Please Select
mg/dl
mg/l
Unit
Send
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