Patient Registration

If your health benefit plan offers the medical travel option through IndusHealth, we can provide you more information about the program and help determine if you may be a candidate. Please fill in this form to provide us some basic information about your needs. One of our Case Managers will get in touch with you generally within one business day.

Patient name

Name of Employer providing medical travel benefit

Patient is:
EmployeeDependent


If Dependent, Name of Employee:

Work location (city & state) of Employee

Are you able to communicate in English?
YesNo


E-mail

Phone

Best time to call (optional)

Do you have a specific health issue or is this just a general inquiry regarding medical travel?
Specific IssueGeneral Inquiry (skip remaining questions)


What type of medical need do you have (check all that apply)
HipKneeShoulderElbowAnkleFootHandNeckBackGastric/Weight-lossHerniaWomen’s healthPharmaOther, please specify:

Have you been evaluated for your current problem?
YesNo


Have you been advised to obtain surgery?
YesNo


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