логотип

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Remote consultation on a fee-for-service basis

* Наименование юр. лица
* Patient's Full Name
* Patient's ID Number
* Patient's Date of Birth (MM/DD/YYYY)
Email Address
* Contact Person's Phone Number
Attach doctor's report, lab and imaging results, and other documents (if available)
Specify the date and time of the online consultation (MM/DD/YYYY)
* Referring Doctor's Full Name
* Referring Doctor's Phone Number
Purpose of Online Consultation

* - Required fields



Hospital Partners