SMSD Inquiry

Special Medical Services Inquiry

    Thank you for your interest in Special Medical Services from Hospitals for Humanity. All fields in the application are required.

    Basic information

    First name

    Last name

    Email

    Phone number

    Street address

    Street address continued

    City

    State/Province

    Zip/Postal code

    Country

    Gender
    FemaleMale

    Age

    Medical history

    What symptoms do you currently have or have had in the past?
    (If your symptoms include pain, please describe how severe the pain is and how long it has lasted.)

    When did you start experiencing the symptoms?

    Have you been diagnosed?

    NoYes

    When were you diagnosed?
    If you haven't been diagnosed, please type "N/A."

    What were the results of diagnosis? (Please be as detailed and thorough as possible.)
    If you haven't been diagnosed, please type "N/A."

    What kind of treatment have you received so far?
    If you haven't received any treatment, please type "N/A."

    Please list your current medications.
    If you are not currently on any medications, please type "N/A."

    Please check any of the following that apply to you.
    Smoke cigarettesDrink alcoholHave a drug addictionNone of these

    Do you think you are stressed or depressed? Please check as many of the boxes below that apply to you.
    StressedDepressedNeither