Second medical opinion

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Personal information

Is your consultation about a neuro-ophthalmological diagnosis?

How would you prefer to receive our second medical opinion?

Name*

First surname*

Second surname

Date of birth*

Gender*

Document type*

Identification number*

Telephone prefix

Telephone number*

Email address*

Nationality*

Address*

Zip code*

Country of residence*

Province*

City*

Province*

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Medical history

1. Do you have a general medical history?*NoYes

Indicate your medical history* (E.g.: Diabetes, arterial hypertension, heart, kidney, liver or brain diseases, etc.)

2. Do you have an eye medical history?*NoYes

Indicate your eye medical history* (E.g.: Cataract, retinal detachment, strabismus, eye traumatism, etc.)

3. Do any of your relatives have any eye diseases?*NoYes

Indicate which one* (E.g.: retinal detachment, pigmentary retinitis, glaucoma, etc.)

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Use of medication

4. Are you currently taking any medication?*NoYes

Indicate the name of the medicine and the dose prescribed*

5. Do you wear glasses?*NoYes

Indicate whether they are for near, far or both distances*

6. Do you use contact lenses?*NoYes

Indicate whether they are soft, rigid or Orto-k*

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Diagnosis

7. What has your ophthalmologist diagnosed you with?*

8. How long has it been since you were diagnosed?*

9. Which eye is affected?*

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Symptoms

10. Have you noticed loss of vision, blurred vision or double vision?*NoYes

Specify the answer*

Indicate since when*

Was it after a hit in the eye?*NoYes

11. Have you had eye pain, any other symptoms such as tearing, red eye, foreign body sensation or do you have any eyelid injury?*NoYes

Indicate the symptoms presented*

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Treatment received

12. Have you received any ophthalmologic treatment?*NoYes

Indicate treatment received*

Indicate date of treatment received and/or duration of treatment*

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

13. What questions would you like to ask our ophthalmologist? Write between one and three questions that you would like to have answered with the second opinion you are requesting.

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Medical documentation

You are kindly requested to enclose all reports and test results available. We accept documents in English, French, Spanish, Catalan or Arabic. The files must be in either of the following formats: pdf, image (gif, jpg, jpeg, png) or compressed in a zip file.

I consent to the processing of personal data, according to the following terms.

In accordance with the provisions of the General Data Protection Regulation [REGULATION (EU) 2016/679], we bring to your attention the following information on the processing of personal data. Responsible parties: Institut Català de Retina, S.L., Institut Català de Cirurgia refractiva, S.L. (hereinafter ICR) Contact Data Protection Delegate: C/Pau Alcover nº 67 08017 Barcelona - rgpd@icrcat.com Purpose: The purpose of the treatment is to provide you with the information you requested. Legitimation: The legal basis for the present treatment is the request for the provision of medical-health and social treatment services made by the users of our center. Recipients: The recipients of the information are the departments and delegations in which ICR is organized, in part or in whole. Other recipients of the information are also the insurance company or mutual benefit society under the policies or coverage of which, as a patient, you are a beneficiary (including labor insurance). ICR may provide information on the services provided to them, as they are essential for such coverage, in order to proceed to their authorization or, in the case of Labor Insurance, to the processing of the corresponding registration, cancellation or labor report, and to their billing. The recipients may also be official public or private entities that, due to legal obligation or material necessity, must access the data, for the appropriate provision of medical-health and social assistance, which is the purpose of the processing of this data. In those cases in which the use of specific surgical material is necessary for treatment, your personal data may be communicated to the supplying entities, solely and exclusively, for the previously described purpose. Rights: At any time, you may exercise your rights of access, rectification, deletion, opposition, limitation of processing and/or data portability by writing to the Data Protection Officer (DPD) at the address provided in the Contact. You may also revoke consents to other processing and may request further information from the DPD about the procedures carried out. In the event that you consider that your rights have been violated, you may file a complaint with the competent Data Protection Supervisory Authority. Preservation: The data collected for healthcare provision will be kept in accordance with current legislation on the conservation of medical records.

Personal information
Medical history
Use of medication
Diagnosis
Symptoms
Treatment
Medical documentation
Payment

Payment

Thank you for completing the personal details and the health questionnaire. Our patient care department will contact you by phone or email if a clarification is needed

Consultation about a diagnosis of neuro-ophthalmology:

How will you receive our second medical opinion:

Service price:

Within a maximum period of 7 business days from the confirmation of payment we will contact you to send our assessment or to arrange an online appointment.

Thank you very much

Second medical opinion

Personal information

Medical history

Use of medication

Diagnosis

Symptoms

Treatment received

Medical documentation

Payment

Do you have any questions?

ICR Ganduxer Headquarters

ICR Ganduxer Headquarters

ICR Pau Alcover

ICR Pau Alcover

Clínica Bonanova Surgical Center

Clínica Bonanova Surgical Center

ICR Cerignola

ICR Cerignola

ICR Terrassa

ICR Terrassa

ICR Gràcia Delegation – Clínica Ntra. Sra. del Remei

ICR Gràcia Delegation – Clínica Ntra. Sra. del Remei