Boston Children's Hospital Heart Center Second Opinion

Requester Information

Is this a Second Opinion for:

Your child Yourself Your fetus (baby not born yet) Other

Terms and Conditions (Review and Accept)

In order for our doctors to give you a useful and valuable second opinion, it is essential that you collect and send us the relevant clinical documentation. This often includes operation notes, last cardiology clinic note, echo reports, echo images, catheterization reports, and catheterization images.
This request will typically result in a written review or summary, but is not meant to be a real-time consultation for urgent issues.
For all patients outside of Massachusetts, a copy of the written summary must go to a medical provider in your home state.

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Parent/Guardian Information

Parent/Guardian First Name:

Parent/Guardian Last Name (Surname):

Parent/Guardian Date of Birth:

Parent/Guardian E-mail:

Parent/Guardian Secondary E-mail:

Parent/Guardian Phone Number:

Parent/Guardian Preferred Languages For Communication:

Do you require an interpreter during medical visits?

Yes

What is your address?

Primary Address Secondary Address

Parent/Guardian Primary Country of Residence:

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Parent/Guardian Primary Address Line 2:

Parent/Guardian Primary City/Town:

Parent/Guardian Primary State/Province/Region:

Parent/Guardian Primary Zip/Postal Code:

Parent/Guardian Secondary Country of Residence:

Parent/Guardian Secondary Address Line 1:

Parent/Guardian Secondary Address Line 2:

Parent/Guardian Secondary City/Town:

Parent/Guardian Secondary State/Province/Region:

Parent/Guardian Secondary Zip/Postal Code:

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Referring MD Information

Who is your referring primary care physician?

Primary care physician contact info:

Who is your primary/referring cardiologist?

Primary/Referring cardiologist contact info:

Who is your referring obstetrician/maternal fetal medicine clinician?

Obstetrician/maternal fetal medicine clinician contact info:

Do you want us to send second opinion letter to your:

Requested clinical program:

Do you have a preferred surgeon at Boston Children's Hospital?

Yes

Select preferred surgeon (optional):

Do you have a preferred cardiologist at Boston Children's Hospital?

Yes

Enter preferred cardiologist (optional):

Preferred surgeon or cardiologist will be attempted to be met, but may not be possible.

Is the patient currently an inpatient, or hospitalized at another hospital?

Yes

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Please upload all available medical reports and records. You may need to contact your doctors to obtain them. Documents in PDF format are preferred. In particular, we need the following important documents.

Most recent cardiology summary or outpatient clinic visit
Any catheterization reports
Any operative reports
Any other diagnostic testing reports and imaging (Cardiac MRI or Cardiac CT)
List of medications
Vaccination records
Echocardiogram and catheterization images are generally very large files and will need to be uploaded using a different method. Your case coordinator will be in contact with you on how to upload them to our systems. DICOM is the preferred format. Often your hospital will provide the echocardiogram on a CD/DVD. This CD/DVD will contains hundreds of files. To prepare for transfer to our system you can combine and compress them into a single zip file. If you are unsure how to accomplish this please wait for your coordinator to contact you.

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Boston Children's Hospital

Requester Information

Parent/Guardian Information

Patient Information

Referring MD Information

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