Patient Informed Consent
Your physician will require that you acknoledge and sign this form for a Virtual Second Opinion from Dr. Guttler and his Santa Monica Thyroid Diagnostic Center.
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Patient's Name: ___________________________________________.
As your treating physician, I am able to arrange a physician consultation organized through the internet from Dr. Richard Guttler, Director of the Santa Monica Thyroid Diagnostic Center, at www.thryoid.com. I believe you may benefit from information I learn through such a thyroid consultation. In order to help you decide whether you want to agree to this, I would like to explain how the consultation works.
Consultation Arrangement
With your permission, I will submit your records including your name, address, date of birth, nature of your thyroid condition, related thyroid history, thyroid scans, and ultrasounds to Dr. Guttler. If needed, I will provide additional information to Dr. Guttler. I will send this information by mail. Dr. Guttler will provide me with a written report of his findings and recommendations. I will review the report as your treating physician and contact you to explain the options suggested and recommendations by the thyroid consultant. Because you requested this consultation, it may be only an indirect relationship between Dr. Guttler and yourself because this is mainly directed as a physician-to-physician thyroid consultation on your behalf.
Confidentiality
Dr. Guttler and his staff will use your medical information to consult with me and will keep this information confidential in accordance with applicable laws. Your medical information will be seen by only Dr. Guttler and other authorized individuals of his staff. The patient information I submit and the report from Dr. Guttler will be part of your medical records I maintain. Dr. Guttler will also keep a copy at the Santa Monica Thyroid Diagnostic Center.
Patient's Signature: _____________________________________________________
Date: ________________________________________________
Physician Name: _______________________________________
Address: _____________________________________________
