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Submit Your Medical Case for Dr. Mingjun Zhang’s Online Oncology Consultation
张明军医生远程肿瘤视频会诊病例提交表
Section 1: Patient Information
Full Name
*
Date of Birth
*
Gender
*
A
Male
B
Female
C
Other
D
Prefer not to say
Country / Region
*
Email Address
*
WhatsApp / Phone Number
*
Preferred Language
*
A
English
B
Chinese
C
Need interpreter support
D
Other
Are you the patient?
*
A
Yes
B
No, I am submitting on behalf of a family member
Section 2: Medical Condition
Main diagnosis or suspected diagnosis
*
Example: gastric cancer, liver cancer, colorectal cancer, suspected tumor, etc.
When was the diagnosis made?
*
Main symptoms or concerns
*
Current cancer stage, if known
*
Has pathology diagnosis been confirmed?
*
A
Yes
B
No
C
Not sure
Previous or current treatments
*
Surgery
Chemotherapy
Radiotherapy
Targeted therapy
Immunotherapy
Ablation
Traditional Chinese medicine
Other
None yet
Please briefly describe previous or current treatments
*
Current medications
*
Main question for Dr. Mingjun Zhang
*
What do you most want to ask during the consultation?
Section 3: Medical Records Upload
Upload pathology report
*
Click to choose a file or drag here
Size limit: 10 MB
Upload imaging report
*
Click to choose a file or drag here
Size limit: 10 MB
CT, MRI, PET-CT, ultrasound, X-ray report, etc.
Upload lab test results
*
Click to choose a file or drag here
Size limit: 10 MB
Upload previous treatment summary or discharge summary
*
Click to choose a file or drag here
Size limit: 10 MB
Upload other medical documents
*
Click to choose a file or drag here
Size limit: 10 MB
Section 4: Consultation Preference
Preferred consultation date
*
Preferred time zone
*
Example: New York EST, London GMT, Singapore SGT
Do you need interpreter support?
*
A
Yes
B
No
C
Not sure
Would you like a brief written consultation summary if available?
*
A
Yes
B
No
C
Not sure
Section 5: Consent
I understand that this online consultation is not for emergency medical conditions and does not replace an in-person examination when required. Medical advice is based on the information I submit and the video consultation. No treatment outcome is guaranteed.
*
I understand and agree
I agree to share my medical information with the international patient coordination team and the consulting specialist for the purpose of arranging this online consultation.
*
I agree
Submit