New Patient Intake Form

New Patient Intake Form

Following your submission you will be contacted by a Mav Doc Care Coordinator who will get to know your medical circumstances and provide an estimate for the critical research to find you the best doctor. Once you accept the estimate your research will be complete, and you will receive an agreed upon invoice in conjunction with your final report.

Average cost: $200-400

Average timeline: 3-5 business days

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Subject

Please provide an introductory description of your medical situation/requirements for our staff to ensure you are paired with the best Care Coordinator. This includes any pre-existing conditions that must be taken into consideration.

Please provide your medical insurance carrier, where you would like to receive medical treatment, and any additional and relevant administrative considerations.