Intake Form - Patient

Personal Information:

First Name:

Last Name:

Date of Birth:

Gender

Male Female

Email:

Phone No.:

City:

State:

ZIP Code:

Country:

Current Health Information:

Height:

Weight:

Blood Type:

Any known allergies?

Yes No

Current Medications:

Current Medical Conditions

Primary Care Physician’s Name:

Primary Care Physician’s Phone No.:

Date of Last Physical Exam:

Health History:

Have you had any accidents or injuries in the past?

Yes No

Are you currently experiencing any pain or discomfort?

Yes No

Treatment Preferences:

Would you like to receive treatment at your home or a facility?

Home Facility

How urgent is the treatment?

Referral Information:

How did you hear about MD Global Care?

Types of facilities or products you refer:

Legal Representation:

Are you currently represented by a personal injury attorney?

Yes No

Would you like us to provide a personal injury attorney for your case?

Yes No

Types of cases

Medical Records:

Have you ever been diagnosed with Cancer?

Yes No

Do you have all your MRI and past medical history scans?

Yes No

Would you like us to schedule an appointment at one of our advanced testing facilities to update your medical history?

Yes No

Do you have Insurance?

Yes No

Please Specify Provider:

Current Healthcare Providers:

Do you have a current medical doctor?

Yes No

Do you have all your current health records within the past year?

Yes No

Would you like us to provide an appointment at one of our health servicing centers or test centers in your country, state, and ZIP code?

Yes No

Additional Information:

Do you have any additional comments or questions for MD Global Care?

Consent Agreement:

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