Intake Form - To Become a Representative

Personal Information:

First Name:

Last Name:

Email:

Phone No.:

Street Address:

City:

State:

ZIP Code:

Country:

Professional Information:

Current Occupation:

Years of Experience:

Industry Experience:

Past Associations with Clinics or Healthcare Facilities:
Yes No

Are you currently associated with any other clinics, facilities, or personal injury attorneys?
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:

Role and Interests:

Are you looking to become a representative to provide treatments for clients globally?

Yes No

Are you interested in working as a referral source with our attorneys and clinics?

Yes No

What kind of role do you want to have on the platform?

Providing Treatments Referral Source Both

Subscription Details:

Are you aware of the $29/month subscription fee, paid upfront for the year, to access the CPA schedule and referral-based system?

Yes No

Services Offered:

Do you have clinics or healthcare facilities that you can bring to the MD Global Care platform?

Yes No

Do you have personal injury attorneys you can refer to the platform?

Yes No

Network and Access:

Are you interested in having access to our global network of facilities, MRI facilities, personal injury attorneys, doctors, clinics, products, and equipment offerings?

Yes No

Experience and Skills:

Describe your past experience relevant to the role you wish to take on the platform:

Have you been involved in any referral-based or commission-based systems before?

Yes No

List any specific skills or expertise you have that could benefit your role as a representative:

Additional Information:

Please provide any additional comments or questions you may have:

Consent Agreement:

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