Intake form

Name *

Email address *

What is your primary purpose for using our services?

Please select at least one option.

Seeking medical translation assistance

Looking for information on our clinics

Interested in our medical software

Inquiring about our new translation app

Which medical specialties are you interested in?

Please select at least one option.

General Medicine

Pediatrics

Cardiology

Orthopedics

Dermatology

Psychiatry

What is your preferred method of communication?

How did you hear about us?

What is your location?

What is your preferred language for communication?

Are you currently a patient at one of our clinics?

Additional questions or comments

Eastern Medical Corporation