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Medical Case Evaluation

Please complete the form below so our medical team can review your case and provide appropriate guidance.

Medical Case Review

Glory Assistance assists clients seeking medical treatment abroad by coordinating with trusted partner hospitals and medical specialists.

The purpose of this form is to collect relevant medical information so it can be reviewed and shared with appropriate doctors and healthcare facilities. Glory Assistance does not provide medical diagnoses, medical opinions, or treatment decisions.

Please complete the form with accurate information regarding your condition, medical history, and any available medical documents. All information submitted is treated with strict confidentiality and used solely for case review and coordination purposes.

Medical Evaluation Form

Medical Case Evaluation Form

1. Personal Information

Tell us who you are

2. Medical Condition

This helps our doctors understand your case

3. Medical History & Existing Condition

Select all that apply

4. Treatment Request & Preferences

Helps us find the best solution for you

5. Urgency & Travel Ability

Important for planning and safety

6. Additional Information

Optional but helpful

7. Consent & Declaration

To protect your information and allow us to contact you

Important Information
Medical reports are not required at this stage. After submitting this form, you will receive a Medical Case Reference Number. Please include this reference number when sending any medical reports, test results, or documents via email or WhatsApp.
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