Free Orthopedic Second Opinion Form
Share your concern and upload relevant records for Dr. Timothy Keating’s review.
About You
Patient name
*
First Name
Middle Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
State of residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
Preferred contact method
*
Phone
Email
Are you completing this form for yourself or someone else?
*
Myself
Someone else
Submitter name
First Name
Middle Name
Last Name
Your Orthopedic Concern
Orthopedic area
*
Hip
Knee
Other
Laterality
*
Right
Left
Both
Not applicable
Main concern
*
How long has this been present?
*
Known diagnosis, if any
Treatments already tried
Has surgery been recommended?
Yes
No
Not sure
If surgery was recommended, what procedure?
Have you already had surgery for this problem?
Yes
No
If yes, what procedure and approximate date?
Questions for Dr. Keating
*
Records and Imaging
Records and imaging uploads
Office notes and consultation reports
Upload a File
Drag and drop files here
Choose a file
Cancel
of
X-ray, MRI, or CT reports
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Operative reports
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Other relevant medical records
Upload a File
Drag and drop files here
Choose a file
Cancel
of
I need help obtaining my records.
I need help obtaining my records.
Acknowledgments
Authorization to Review Information and Contact Me
*
I authorize Dr. Keating and his care team to review my submitted information and contact me about this request.
Free Second Opinion and Separate Services
*
I understand the initial second opinion is free and that any follow-up appointments, testing, or treatment are separate services and may be billed to me or my insurance.
Need for Examination or Additional Testing
*
I understand that an examination or additional testing may be needed before a definitive recommendation can be made.
Not for Urgent or Emergency Concerns
*
I understand this service is not for urgent or emergency concerns, submissions are not continuously monitored, and medical emergencies require calling 911.
Request My Free Second Opinion
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