*First Name  
*Surname  
*Email    
*Birth Date (MM/DD/YYYY)    
*Gender  
*Phone Number (CountryCode - Number)  
*Height  
*Weight  
*Assist America Reference #  
*Insurance Policy # (through which you have Assist America)  
*Initial Diagnosis  
Are you currently taking any medications?
If Yes, please list below (separated by commas)
Specify any medications and/or substances
that you are allergic to or cannot take
(List all food, plant, animal, environmental
or other medication allergies separated by commas)
*Reason for Consultation  
*What are your current concerns?  
*Are you presently suffering from any acute illness? (If Yes, please explain)  
*What are the questions that you would like the physician to address?  
Do you have any of the following conditions?
Describe in more detail above conditions
Do you have a strong family history or any serious
illnesses (Cancer, Heart Disease, etc.)
- please provide detail
List any past hospitalizations
(date and reason)
Detail your past surgical history
(please list surgery and date)
Please provide any additional information
that may be key to your case

AGREE TO TERMS

I understand that authorizing the disclosure of this health information is voluntary. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing.

I understand that this revocation will not apply to any material or information that is already released in response to this authorization. The information obtained by Assist America will be used by Assist America and third parties that provide second medical opinions for Assist America.

I understand that in order for Assist America to obtain a second medical opinions the information that I provide will be received by Assist America’s operation center in the United States. I further understand that the transmittal of the information may be into the United States and from the country in which I am located. I understand that this transfer is required in order for me to obtain a second medical opinions through Assist America and necessary for Assist America to fulfill its obligations.

All third-party providers or such services are also bound by laws governing privacy and personal health information protection obligations.

Assist America will not distribute my healthcare information to any third party except to obtain a second medical opinion, in connection with the rendering of this service

I agree with the terms and conditions above.  

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