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Medical Intake Form
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Patient Full Name
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Form Filled By Patient Self or Other
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Phone
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Email
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Birth Date
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Gender
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Height and Weight
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Type of USA Services Needed
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Online Expert Medical Opinion
Second Opinion
Treatment at USA Hospitals
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Any Preferred Hospital(s) or Specialist To Request
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Reason For Requesting Above USA Services
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Current Symptoms
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Past Medical and Surgical History
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Upload any Hospital Discharge Reports
Upload any Doctor's Note
Upload any Prescriptions (Can upload multiple files)
Upload any Lab Reports (Can upload multiple files)
Upload any MRI - Images and Reports (Can upload multiple files)
Upload any USG - Images and Reports (Can upload multiple files)
Upload any CT - Scan Images and Reports (Can upload multiple files)
Any other medical information
Any Medical Images / Reports you can also email to
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or message on whatsapp +18186691529
3 Main Questions For USA Specialists
PATIENT CONSENT:
I hereby authorize MediPocket, Inc. to use the platform for telecommunication / consultation / treatment for evaluating, testing and diagnosing my medical condition.
I agree MediPocket, Inc. to collect and submit my medical records to the hospitals and specialists for evaluation and acceptance of my case.
I understand that my current insurance may not cover the additional fees of the USA services and I will be responsible for any fee, medical expenses.
I agree that my medical records can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept
Patient Consent
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