Intake form

Help us serve you better

Name *

Email address *

What type of medical care do you require?

Please select at least one option.

Dental

Orthopedic

Cardiology

Cosmetic Surgery

Vision

Do you have any existing medical conditions?

Have you traveled internationally for medical care before?

How soon do you need medical treatment?

What is your preferred method of communication?

Are you traveling with anyone?

If yes, please list their names and relationship to you.

Do you have any allergies or sensitivities?

What is your current location?

Additional questions or comments

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