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
Please select
Male
Female
*
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
Please select
Anal cancer
Asbestos cancer / mesothelioma
Cervical/uterine cancer
Bladder cancer
Breast cancer
Ovarian cancer
GIST (Gastrointestinal stromal tumor)
Brain tumors
Head and neck cancer
Skin cancer
Lung cancer
Stomach-intestines-liver
Melanoma
Neuroendocrine cancer
Kidney cancer
Penile cancer
Prostate cancer
Sarcoma
Thyroid cancer
Esophageal cancer
Thymus cancer (Thymoma)
Vulvar cancer
Soft tissue tumor
Testicular cancer
Cancer of unknown primary
Other cancer types
*
Confirmation of appointment
Send confirmation to
Patient
Contact person
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?
Please select
Yes
No
*
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
Specialist
GP
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
*
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