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Medical Coordination Intake Form
Please complete the intake form to initiate your coordination process.
What is your full name?
*
What is your email address?
*
What is your nationality?
*
What is your work and your job title?
*
Briefly describe the medical case you need help with:
*
Upload your most recent medical report(s) and imaging:
*
Click to choose a file or drag here
Size limit: 10 MB
Do you have international health insurance?
*
Do you have international health insurance?
A
Yes I have my policy ready to upload
B
No
Submit
