Concierge Records Service · Step 2 of 3

Tell us about your case

Most patients finish in 8–10 minutes. You can submit for yourself or on behalf of a loved one.

✓

Concierge service is active

Your $149 payment was received. Receipt sent to the email you provided. Complete the intake form below and your concierge will reach out within 1 business day.

Intake form

About 8–10 minutes. You can submit for yourself, on behalf of a loved one, or as a Power of Attorney representative.

About you (the person filling this out)

If you're the patient, you can answer everything here. If you're filling this out on behalf of a loved one, we'll capture their information in the next section.

Your name(Required)

First Last

Your email(Required)

Use the same email you used to pay. This is how concierge will reach you.

Your mobile phone(Required)

Texting is the fastest way to reach concierge.

Who are you filling this out for?(Required)

Myself (I am the patient)

My spouse or partner

My adult child

My parent

A minor child (I am parent or legal guardian)

Someone I hold Power of Attorney for

Other (please explain below)

If "Other", briefly explain your authority to act for this patient

About the patient

If you are the patient, skip ahead — this section is only required when you're filling out on behalf of someone else.

Patient's full name(Required)

First Last

If you are the patient, repeat your name here.

Patient's date of birth(Required)

MM slash DD slash YYYY

Patient's sex assigned at birth

Female

Male

Prefer not to say

This helps us match anatomy-specific opinions. Skip if you prefer.

Patient's home address(Required)

Street Address Address Line 2 City State ZIP Code

State of residence determines which surgeons we can match (state licensure).

Patient's email (if different from yours)

Leave blank if same as yours.

Patient's phone (if different from yours)

Leave blank if same as yours.

The procedure

Tell us what surgery has been recommended and what's prompting the second opinion.

What surgery has been recommended or are you considering?(Required)

Your words are fine — concierge will translate to a CPT code.

Which body part and what's the issue?

A sentence or two is plenty.

Is the surgery scheduled? If so, when?

MM slash DD slash YYYY

Skip if not yet scheduled. Helps concierge prioritize.

Recommending surgeon's name (if you have one)

Skip if no specific surgeon has recommended this yet

Recommending surgeon — city & state

Skip if no specific surgeon has recommended this yet

Hospital or surgery center where surgery would be performed

Have you already gotten a second opinion?

No, this is my first second opinion

Yes, one other

Yes, multiple

I'm still considering whether to

Insurance

Insurance type drives which surgeons we can match you with. Member ID isn't required up front — concierge will collect it if needed.

Insurance type

Commercial (through employer or marketplace)

Medicare

Medicaid

Self-pay (no insurance, or paying out-of-pocket)

Other / not sure

Insurance carrier name

Leave blank if self-pay or unsure.

Member ID (if handy)

Optional — concierge will collect this securely later if needed.

Imaging & prior records

Tell us what records exist and where. Concierge will request copies — you don't need to gather them yourself.

Have you had imaging (MRI, CT, X-ray, ultrasound) for this condition?

Yes

Not sure

Where was imaging done?

List each facility, city/state, and approximate date. Use multiple lines if more than one.

List the providers we should request records from

Name, city/state, specialty for each. Concierge will obtain HIPAA authorization and request records directly.

Anything else?

Brief description of your situation

Optional. Concierge reviews every submission.

Anything urgent we should know?

If you can't wait the typical 14-21 day review window, tell us why so concierge can advise.

Confirmations

Authority to act on behalf of patient(Required)

I confirm I have the legal authority to act on behalf of the patient (either I am the patient, or I am their parent / guardian / spouse / Power of Attorney holder / other authorized representative).

Opinions are voluntary(Required)

I understand that opinions are voluntary. SurgiQuality coordinates the request; surgeons may decline to review. I may receive zero, one, or multiple opinions depending on surgeon availability.

Review window(Required)

I understand the typical review window is 14-21 days from when my case is fully received. If my condition worsens or I cannot wait, I should proceed with my original surgeon and notify concierge.

JavaScript is required to load the intake form. Please call (832) 810-8566 or email info@surgiquality.com and we’ll complete your intake by phone.

Your $149 stays active — if you don’t finish in one session, concierge will follow up by phone or email within 1 business day to complete your intake.

Need help?

Talk to a real person — not a robot

Your concierge can complete the intake by phone if that’s easier.

☎ (832) 810-8566 ✉ [email protected]