International Triage - Request Service

Request Service

Express Inquiry About Medical Treatment

Thank you for your interest in services from International-Triage, LLC (IT).
Please fill out the following electronic inquiry form.
You will be contacted within 48 hours from submitting this inquiry.

Please indicate the urgency of your request by selecting one of the color-coded options

Routine
I am considering the service

Rush Appointment
I want the service

Emergency
Just had a medical crisis

Patient Information

Full Name
	First	Middle	Last
Email
Gender	Male Female
Birthday		(e.g.. 01/01/2006)
Passport Number
If US Citizen residing OUT OF THE USA please provide
SSN
If Non-US Citizen
Country
I have a visa to enter the USA		I need a visa to enter the USA
Best Contact Mode
Preferred Language		If other please indicate
How did you hear about *IT?*

Patient Physical & Mailing Address
Address
City		State/Province
Postal Code		Country
Home Phone		(include country code if outside the USA)
Cell Phone		(include country code if outside the USA)
Other Phone		(include country code if outside the USA)

Payment Information
I authorize charges in the amount of US $______ to my credit card. To read consent form click here
Card Type
Card Number		Name as it appear on Card
Safety Code		Expiration Date
I hereby authorize International-Triage, LLC to charge my card for fees in connection with facilitating remote monitoring services.

Medical Information

What medical services do you need?
When did your symptoms begin?
Please describe your treatment to date and your doctor's recommended course of treatment for managing your medical situation:

Please e-mail, or fax, us a copy of your RELEVANT medical records to __________________. Be sure to include a cover sheet with your name, contact information and number all pages sent. Documents can be provided in English and /or in Spanish and MUST signed by your treating physician.
My Blood Type:

ALLERGIES List all your allergies (medications and others)

MEDICAL STATUS List all existing (active) medical conditions (example: if diabetic, list insulin intake. If hypertensive, list your "normal" blood pressure. List all medications by name and dosage.

MEDICAL HISTORY: List previous operations, procedures, conditions for which you were treated.


Contact Information of the Physician Who Is Currently Treating Me
Physician Name
Type		Specialty
E-Mail
Phone		Cellular
Address
City		State/Province
Postal Code		Country

Insurance Information
ONLY FOR U.S. CITIZENS WITH MEDICARE COVERAGE
If you are covered by Medicare Benefits, please complete the following
Medicare beneficiary number
State of Issuance
Supplemental Insurance Company Name
Group Number / Group ID
Customer Service / Benefits Office Contact Number

Insurance Information
If you are covered by any other medical insurance that is not Medicare, please complete the following
		Name of Insurance Company
		Insurance Policy Number
		Group or Member ID Number
		Name of Policy Holder
		Customer Service Number
		Benefit Authorization Number
Does your health insurance cover medical services out of your country of residence?			Yes No Unknown
If you would like to add any other information you believe would be helpful or leave a further message for the physician referral office, please type it here.


Information collected from this web inquiry, and in subsequent transmittals, will only be used form and in conjunction with, formulating appropriate administrative and medical decisions necessary for responding to this inquiry by International-Triage, LLC. Information provided by the patient does not create any type of relationship between the individual providing the information and participating medical providers of International-Triage, LLC or any physicians, staff, agents and directors, whatsoever. This information is not considered Protected Health Information (PHI) and will be used to contact you because you have requested to be contacted. Additionally, information provided on the website, or in any response to you, is not and cannot be considered medical advice or treatment. International-Triage, LLC, its subsidiaries, participating medical providers, or any of their entities, physicians, staff, agents and directors will not be held liable for, and you will release and hold them harmless from, any claims and/or any direct, indirect, consequential, special, exemplary, or other damages arising there from, whatsoever. Please consult with your doctor for medical advice or treatment for any condition you may have.

If you are experiencing a medical emergency, call 911 and/or go to the nearest emergency room.
I have read, understood and agree to the above.