Patient Intake Form - Vayo Global Care LTD

Full Name *

Date of Birth *

Gender *

Nationality *

Country of Residence *

Phone Number *

Email Address *

Passport Number *

Medical Condition / Diagnosis *

When were you diagnosed? *

Current symptoms *

Previous treatments *

Current medications *

Allergies *

Medical reports

MRI / CT scans

Lab results

Doctor notes

Do you have a passport?

Preferred travel date *

Will you travel with a companion?

Do you require hotel arrangements?

Accommodation Support

Would you like an online consultation first?

Consultation Request

Preferred consultation date *

Consent & Authorization

I authorize Vayo Global Care Ltd to share my medical records with partner hospitals for treatment evaluation.

Signature

Date *