Facility Registration Form

Facility Name *

Contact Person *

Email *

Phone No. *

Country

City *

State *

ZIP Code *

List of services currently offered *

Are you interested in offering stem cell treatments?

Yes

Do you have approved medical staff to administer treatments?

Yes

If no, are you interested in having MD Global Care staff provide treatments at your location?

Yes

Do you have licensed/certified approved medical staff on site to administer IV infusions?

Yes

Do you have licensed/certified approved medical staff to administer large joint injections?

Yes

How did you hear about MD Global Care?

Are you currently sending referrals to attorneys or clinics?

Yes

Types of facilities or products you refer

Are you aware of the $599 monthly subscription fee?

Yes

Are you interested in marketing your facility through MD Global Care?

Yes

Any other information you would like to provide

Intake Form - Facility / Servicing Centre