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I would like to:*

Ask a Question
Submit Case Review

Our team welcomes your Film Review for a fee of $500. To initiate a second opinion, please complete the below form. Once the form is completed, you will be directed to instructions on how to move forward.
Please note: due to high volume, film reviews may take up to 4-6 weeks.

I understand that the Clinical Case Review that I will receive is preliminary and limited because it does not have information typically obtained through a physical examination. The absence of a physical examination could affect the ability to diagnose my condition or injury. This Clinical Case Review is not intended to replace a full medical evaluation or an in-person visit with a physician. I agree to solely assume the risks of the limitations associated with this review and understand that no warranty or guarantee is made to me concerning a specific result or cure of my condition or injury. I have read and agree to be bound by these conditions.*

Yes, I agree
No, I do not agree

In order to complete a case review with our team, you must agree to our terms. If you would like to ask our team a question, please click here and select the option "Ask a Question".

Name*

(First, Last)

Email*

Phone*

City / State / Country*

How did you find us?*

Referring Physician Name

Referring Family/Friend Name

Gender*

Male
Female

Date of Birth*

(MM/DD/YYYY)

With this case review, what can we help you with?*

Discuss surgical options
Discuss alternative treatments
Second opinion

Insurance Provider*

If uninsured, please note that you are uninsured.

Injury Side*

Right
Left
Both

Did your injury occur to your foot and/or ankle?*

Foot
Ankle
Both

Date of Injury*

(MM/DD/YYYY) If chronic, please put date when pain began.

Brief Description of Injury*

Description of Symptoms*

Have you received a diagnosis from another physician?*

Yes
No

If so, please describe the physicians diagnosis

Prior Medical History*

Prior Surgical History*

If no surgical history, please state none.

Current Medications*

If you are not on any medications, please state none.

Case Review Information*

I will download the Review & Payment form and will mail it to the office.

You will receive a Review & Payment document when this form is submitted.

Name*

(First, Last)

Email*

Phone*

City / State / Country*

How did you find us?*

Referring Family/Friend Name

Referring Physician Name

Medical Issue*

Your Question:*

For urgent or acute cases, please call us at 970-476-1100

Response to these inquiries can take several days

Contact

*For urgent or acute cases, please call us at 970-476-1100*

Response to these inquiries can take several days

For urgent or acute cases, please call us at 970-476-1100