Facility Name:
Contact Person:
Email:
Phone No.:
Country:—Please choose an option—AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongoCongo (Democratic Republic of the)Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth KoreaNorth MacedoniaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe
City:
State:
ZIP Code:
Type of Facility Servicing Centre:—Please choose an option—Doctor's OfficesOutpatient ClinicsHigh-End Salons and Med SpasRehabilitation and Physical Therapy CentersWellness and Holistic Treatment CentersDiagnostic and Imaging CentersStem Cell and Regenerative Medicine CentersMental Health and Counseling CentersSpecialty Wellness CentersAt-Home Mobile ServicesIntegrated Health and Wellness ClinicsMed Spas and Aesthetic ClinicsSexual Health and Fertility ClinicsDetoxification and Immune Support FacilitiesSpiritual and Energy Healing CentersFloatation Therapy CentersPain Management Clinics
Doctor's Offices:—Please choose an option—General practitionersFamily medicine officesSpecialty care offices (cardiology, endocrinology, etc.)
Outpatient Clinics:—Please choose an option—Urgent care centersSpecialty clinics (pain management, dermatology, etc.)
High-End Salons and Med Spas:—Please choose an option—Botox and dermal filler centersStem cell microneedling servicesAdvanced skincare and laser treatment centers
Rehabilitation and Physical Therapy Centers:—Please choose an option—Sports injury recovery centersOccupational therapy facilitiesJoint and musculoskeletal clinics
Wellness and Holistic Treatment Centers:—Please choose an option—Naturopathic clinicsEnergy healing centers (e.g., Reiki, acupuncture)Functional medicine facilities
Diagnostic and Imaging Centers:—Please choose an option—MRI and CT scan centersBlood testing and genetic labsX-ray and ultrasound facilities
Stem Cell and Regenerative Medicine Centers:—Please choose an option—Stem cell processing labsRegenerative surgery clinicsCryopreservation facilities
Mental Health and Counseling Centers:—Please choose an option—Psychiatric outpatient clinicsBehavioral therapy centersEnergy Enhancement System (EES) therapy centers
Specialty Wellness Centers:—Please choose an option—Floatation tank (sensory deprivation) centersInfrared sauna facilitiesCryotherapy and light therapy centers
At-Home Mobile Services:—Please choose an option—Mobile IV therapy and infusion servicesIn-home nurse-administered carePortable Energy Enhancement Systems (EES)
Integrated Health and Wellness Clinics:—Please choose an option—Integrated medicine clinicsHolistic hospitalsWellness hospitals
Med Spas and Aesthetic Clinics:—Please choose an option—Anti-aging centersLaser treatment facilitiesBody contouring and sculpting clinics
Sexual Health and Fertility Clinics:—Please choose an option—Hormonal therapy centersFertility and IVF clinicsMen's and women's health centers
Detoxification and Immune Support Facilities:—Please choose an option—Vitamin and nutrient infusion loungesHeavy metal detox facilitiesHyperbaric oxygen therapy centers
Spiritual and Energy Healing Centers:—Please choose an option—Chakra alignment clinicsPranic healing centersMeditation and mindfulness centers
Floatation Therapy Centers:—Please choose an option—
Pain Management Clinics:—Please choose an option—Joint pain and arthritis clinicsNeuropathic pain centersTrigger-point therapy facilities
List of services currently offered:
Are you interested in offering stem cell treatments?YesNo
Do you have approved medical staff to administer treatments?YesNo
If no, are you interested in having MD Global Care staff provide treatments at your location in All services center:YesNo
Do you have licensed/certified approved medical staff on site to administer IV infusions:YesNo
Do you have licensed/certified approved medical staff to administer large joint injections:YesNo
How did you hear about MD Global Care?—Please choose an option—Media (TV, Radio, Online Ads)Social Media (Facebook, Instagram, YouTube Etc)Family / FriendsMedical Professional (Doctor, Medical Staff, Etc)Representative
First Name
Last Name
Email
Phone No.
Are you currently sending referrals to attorneys or clinics?
YesNo
Types of facilities or products you refer:
Are you aware of the $599 monthly subscription fee?
Are you interested in marketing your facility through MD Global Care?
Any other information you would like to provide:
