Testing Centre Partner Registration

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Testing Centre Information

Facility Name *

Year Established *

Number of Employees *

Website URL *

Social Media Links *

Contact Person *

Contact Person’s Title *

Email *

Phone No. *

Street Address *

City *

State *

ZIP Code *

Country*

How many testing centers do you operate? *

Where are your testing centers located globally?

Street Address *

City *

State *

ZIP Code *

Country

Diagnostic Services

What types of diagnostic services do you offer?

Do you perform full medical scans?

Yes

Do you have MRI facilities?

Yes

Facility Details

How many facilities do you have? *

Where are your facilities located globally?

Street Address *

City *

State *

ZIP Code *

Country

Partnership and Collaboration

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

Yes

Are you looking to provide referrals to the MD Global Care platform?

Yes

Are you currently working with attorneys for patient referrals?

Yes

Would you be interested in working with the MD Global Care referral system based on representatives and attorneys?

Yes

Referral Information

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 *

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.