Intake Form - To Become a Representative

Full Name:

Email:

Phone No.:

Country:

City:

State:

ZIP Code:

Callback Date:

Callback Time:

Current Occupation:

Industry Experience:

Do you have any prior medical industry experience?

Yes No

How did you hear about MD Global Care Platform?

Are you currently sending referrals to attorneys or clinics?

Yes No

Types of facilities or products you refer:

Do you have a location center?

Yes No

Location Name:

Address:

Country:

State:

Zip Code:

Are you aware of the $29 monthly subscription fee paid upfront for the year to have access on MD Global Platform for a fee payout schedule?

Yes No

Any other information you would like to provide: