Request second opinion for patients  
You can use this form to request a second opinion yourself. Please make sure that you have your complete medical history and a referral from your physician. Are you submitting a request from abroad? Please make sure that all documentation has been translated into Dutch or English. After submitting your form, Poliplanning will process your data. You will be notified about the status of your second opinion within five days.

Questions?
Do you have any questions while completing this form? Please contact us at our general phone number (+31 (0)20 512 9111) and ask for the Patient Information Center. For more information about the receipt of your form or the status of your request, please contact the same phone number and ask for Poliplanning.
For more information about a second opinion and potential costs, please see our second opinion page.

Fields marked with a * are mandatory
 
Patient data Last name *
  Initials *
  Sexe *
  Date of birth *  mm-dd-yyyy
  Address *
  House no. /  addition *  
  Postal/zip code *
  City *
  Phone number *
  E-mail address *
  Burger service number (BSN)   *
  Have you visited the NKI before?
  Diagnosis/suspected *
   
     
Confirmation of appointment Send confirmation to

 
Reference information Referral general practitioner (preferably from specialist at current hospital)
  Information  
Medical history and imaging, Pathology, and OR reports.
   
 
   
   
   
  CD-ROM with x-rays, (nuclear) diagnostic imaging, or pathological material mailed to the NKI? *
  Date of submission
  The CD-ROM or DVD can be submitted to: Antoni van Leeuwenhoek t.a.v. Radiologisch Archief, Postbus 90203, 1006 BE Amsterdam.
 
Data referrer Referrer
  Name of referrer *
  Name of institution *
  Specialism
  E-mail address
  Phone number
  Contact person referrer for additional data
  Comments referrer
     
     
  Type the code to verify
  *