| Who is your referring doctor? |
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| Have you seen Dr Dohrmann before? |
Yes
No
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| Have you or your doctor sent or faxed a medical referral to Dr Dohrmann's office yet? |
Yes
No
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| Is your condition related to a motor car accident? |
Yes
No
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| Please describe the diagnosis of your condition as you understand it, in your own words (for example, a pinched nerve in the back): |
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| Have you had an MRI scan (not a CT scan) in the past six months? |
Yes
No
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| Which one or more of these best describes your situation? |
I have asked my doctor for a referral to Dr Dohrmann
My doctor has recommended Dr Dohrmann
I have seen a neurosurgeon already but Dr Dohrmann has been recommended for a second opinion
My solicitor suggested I see Dr Dohrmann
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| Surgery is |
Not on my agenda at all
A last resort and I don't think I'm at that stage
Something I might consider
Something I think I probably need
Something I think I will definitely need
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| How long has the problem for which you would like to see Dr Dohrmann been a concern to you? |
About a week
About a month
More than 3 months
More than 6 months
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| Please enter up to three questions that you would hope to have answered at an appointment: |
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| Is there any other information or comments that you would like to add here? |
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| What is the best way for us to contact you regarding your request for an appointment? |
Mobile phone
Home phone
Work phone
Email
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| Mobile phone |
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| Home phone |
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| Work phone |
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| Please enter your name: |
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| Email Address: |
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