Physician to Physician Consult Request

(*) Required information

Physician Information:


First Name*:
Last Name*:
Address 1*:
Address 2:
City*:
State*:
Zip*:
Telephone*:
Fax:
Email*:
Degree:
Specialty:

Patient Information:

Brief Clinical Summary*:

Pertinent Exam Findings:

Immunology Lab Data (include imaging or biopsy data and reports):

Specific Questions:

Patient Gender*:

Male

Female

Presumed Diagnosis:

How did you hear about the IDF Consulting Immunologist Program?:

By requesting that your information be conveyed to a Consulting Immunologist (a "Consulting Immunologist") and that a response be provided under the Consulting Immunologist Program ("Program") you ("You" or the "Requesting Physician") represent, warrant and agree to the Immune Deficiency Foundation (:IDF:) and to the Consulting Immunologist as follows :

The Program is provided solely as an educational and informational service by the IDF in accordance with its mission as a national, non-profit organization to improve the diagnosis and treatment of patients with primary immunodeficiency diseases through research and education. The IDF is not a health care provider and does not provide any medical advice to any Requesting Physician or any patient. The IDF is not responsible for the provision of a response or for the timeliness or content of any Consulting Immunologist response to a Requesting Physician's request. The IDF does not credential the Consulting Immunologists and makes no representation or warranty as to the qualifications of any Consulting Immunologist.
The Consulting Immunologist responses are not to be used to direct care of any patient of a Requesting Physician. You are solely responsible for clinical decision making for Your patients. The Consulting Immunologist does not have a physician-patient relationship with any patient under the care of a Requesting Physician. Consulting Immunologists do not undertake any verification of information provided by a Requesting Physician, do not examine any patient or review any patient medical record, but solely provide general educational and informational input based on the information that You provide, notwithstanding that You may use an interaction with a patient of the Requesting Physician to generate a request for information under the Program.
You agree that neither IDF, nor any Consulting Immunologist, is liable for, and shall be held harmless by you for, any costs and expenses, including reasonable attorneys' fees, arising directly or indirectly from the provision of a response to your request for information, including without limitation any direct, indirect, punitive, general, special or consequential damages.

I agree to the terms and conditions stated above*

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