Medical Intake Form


  1. I hereby authorize MediPocket, Inc. to use the platform for telecommunication / consultation / treatment for evaluating, testing and diagnosing my medical condition.
  2. I agree MediPocket, Inc. to collect and submit my medical records to the hospitals and specialists for evaluation and acceptance of my case.
  3. 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.
  4. 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
MediPocket USA