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Registration
  Registration Form
Please fill the following information and submit the form so that we can understand the medical treatment solution you are seeking. An GLOBAL Medical care representative will call you to further discuss how we can help you.

You may contact us at 1-800-614-6685, Fax us at 1-800-516-4109 or email us at contact@glomedcare.com

 
First Name* :
Middle :
Last Name :
Street Address :
City * :
State :
Zip code/Pincode :
Country :
Email ID* :
Home phone* :
Work phone :
Cell phone :
Your preferred contact method :
Best time to call you :
Your Time zone :
Age :
What Medical Treatment/Procedures
are you considering?*		 :
If Others Please Specify :
Would like to give some additional information on your requirements? Please use the box below
Are you looking for a Wellness Program OR Alternative medical solutions? We offer a wide range
Yes No
How soon do you need this treatment?* :
Have you discussed your medical Treatment need(s) with a physician?
Yes No
Have you traveled abroad before? *
Yes No
Do you have a passport?
Yes No
Would you like to add a vacation to your stay? If so please indicate
A side trip to nearby tourist attractions
A post recovery stay at a Spa, Resort or Hotel
Visit a wellness center
How Did You Find Out About Us * :
What will be your preferred method of payment?* :
Any comments or questions :

                            

* Mandatory Fields
 
 
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