Patient Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Country of Residence
*
Treatment Information
Area of Interest
*
Please Select
Cosmetic & Plastic Surgery
Dentistry
Hair Restoration
IVF & Fertility
Health Assessment
Bariatric Surgery
Orthopedics
Ophthalmology
Dermatology
Other
Procedure of Interest
Preferred Treatment Timeline
Within 1 Month
1–3 Months
3–6 Months
More Than 6 Months
Brief Description of Your Goals
Medical Records Upload
Upload Categories
*
Medical Records
Operative Reports
Laboratory Results
Pathology Reports
Radiology Reports
CT Scan Reports
MRI Reports
Treatment Summaries
Before Photos (Optional)
Other Supporting Documentation
Upload Files
*
Upload a File
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of
HIPAA Authorization
Authorization to receive, review, store, and transmit my medical records for treatment evaluations and consultations with healthcare providers I select
*
Agree
I acknowledge that NoveaMed is not a healthcare provider and serves solely as a medical travel coordination and concierge service
*
Agree
I acknowledge that my information may be securely shared with healthcare providers located outside the United States for treatment evaluation purposes
*
Agree
Electronic Signature
Full Legal Name
*
First Name
Middle Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Medical Records Securely
Submit Medical Records Securely
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