Attorney Referral — Personal Injury

Attorney Information:

First Name:

Last Name:

Email:

Phone No.:

Street Address:

City:

State:

ZIP Code:

Country:

Professional Information:

Law Firm Name:

Years of Experience:

Areas of Practice:

Issuing State/Country:

Expiry Date:

List all States/Countries where you are licensed to practice:

Primary Office Location:

Address:

City:

State:

ZIP Code:

Country:

Referral Practices:

Are you currently referring clients to other medical facilities?

Yes No

Are you interested in referring clients to MD Global Care facilities?

Yes No

Are you interested in collaborating with MD Global Care for patient referrals?

Yes No

Referral Information:

How did you hear about MD Global Care?

Are you currently sending referrals to attorneys or clinics?

Yes No

Types of facilities or products you refer:

Current Referral Network:

Are you currently sending referrals to any other attorneys or clinics?

Yes No

What kind of referrals do you typically send out?

Fee Payout Schedule:

Are you interested in understanding the fee payout schedule?

Yes No

Are you willing to accept referrals from MD Global Care representatives?

Yes No

Geographical Reach:

Please list all states and counties where you can provide referral services:

Services and Collaboration:

Are you interested in collaborating for other legal services beyond personal injury?

Yes No

Are you willing to participate in joint marketing efforts?

Yes No

Additional Information:

Do you have any additional comments or questions?

Consent Agreement:

By submitting this form, I agree to the terms and conditions of collaborating with MD Global Care.