CompassCare Global — Patient Intake Form

This form is by invitation only. Please complete all sections. Your information is kept confidential and used solely for coordination purposes.

First name*

Last name*

Email*

Phone*

Address

Birthday*

Month

Day

Year

Emergency Contact Name & Relationship*

Emergency Contact Phone Number*

Section 2: Procedure & Care Interest

What type of procedure or treatment are you seeking?*

Have you received a diagnosis from a U.S. physician?*

Yes

If yes, what is your diagnosis?

Have you received a treatment recommendation or surgical quote in the U.S.?*

Yes

If yes, approximately what was the estimated U.S. cost?

What is your target timeframe for treatment?*

Section 3: Insurance & Coverage

Do you currently have health insurance?*

Yes

Insurance carrier name

Are you a Medicare or Medicaid beneficiary?*

Yes

Do you have or are you willing to obtain medical travel insurance?*

Yes

Need more information

Section 4: Travel & Logistics

Do you have a valid U.S. passport?*

Yes

In process

Will you be traveling alone or with a companion?*

Alone

With a companion

Do you have any mobility or accessibility needs we should be aware of?

Are you comfortable with an approximate 10–20 day stay in Saigon?*

Yes

Need more information

Section 5: How Did You Hear About Us?

How did you hear about CompassCare Global?*

Section 6: Acknowledgment

I understand that CompassCare Global LLC is a healthcare coordination and concierge travel facilitation company. CCG does not provide medical advice, practice medicine, guarantee outcomes, employ physicians, or direct treatment. I am submitting this form to begin an exploratory conversation only.

Connecting patients to trusted care internationally

info@compasscareglobal.com

Based in the United States

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