Patient Medical History Evaluation Form
Please be advised that the Patient Medical History Evaluation form will be shared with 3 hospitals for evaluation by 3 physicians and to provide estimated treatment cost. Please be accurate with the information you are about to provide. Estimated Completion time: 10-15 minutes.
Medical Information / History
(including over the counter drugs, supplements, vitamins … etc.)?
Allowed file formats: .png, .gif, .jpg, .doc, .xls, .ppt, .pdf - X-ray and MRI images preferably in PDF file.