Intake Form - Medical Staff

First Name:

Last Name:

Email:

Phone No.:

Country:

City:

State:

ZIP Code:

License/Certification Name:

Country/States of Certification:

Specialties:

Years of Experience:

Approved to administer stem cell and regenerative treatments?
Yes No

Interested in telehealth services?
Yes No

Interested in performing in-person treatments?
Yes No

Do you have a flexible schedule?
Yes No

Are you aware of AI-powered medical coding & billing services by MD Global Care?
Yes No

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:

Any other information you would like to provide: