Initial Consult Request Form

Thank you for your interest in Vital Link Healthcare Advocates!

Please complete this form to the best of your ability. The more information you are willing/able to share, the easier it is for us to determine if/how we can help.

This form is HIPAA compliant and securely transmitted using 256 bit SSL (Secure Socket Layer) connection that uses a SHA256 Certificate. This is the same level of protection used by online banking or e-commerce providers.

Name of the person filling out this form:*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Please select "YES" to opt-in to grant Vital Link Healthcare Advocates permission to send text messages. This permission is individualized education, information, and case specific communication and is NOT for marketing purposes. (Data rates may apply). We do not send spam, or share your information with any third party unless we obtain a written HIPAA consent.

YesNo

How did you hear about Vital Link Healthcare Advocates?*

Google SearchNational or Local Patient Advocacy DirectoryWord of mouth referral

At this point in time, how would you describe your current interest in patient advocacy services?*

I'm just a little curious.I'm fairly interested but a lot depends on how much it will cost.I'm very interested in learning more, and ready to move forward.I'm at the end of my rope and can't wait to get started.

Please share with us why you are seeking the services of a professional healthcare advocate? *

How are you hoping we might be able to help?*

What questions do you have for us? *

What type of consultation would you prefer? *

When are you available? (Please provide at least 3 different dates/times)*

I acknowledge that Vital Link Healthcare Advocates is a private, professional healthcare/patient advocacy business and that services provided will NOT be filed, billed, or reimbursed through any insurance company or benefits policy.*

I understand that Vital Link Healthcare Advocates and their associate independent contractors do NOT provide medical recommendations or diagnoses, prescriptions, treatments, or therapies even if licensed to do so.*

I understand that independent patient advocates also do NOT directly provide hands on medical, nursing, or personal care, legal services or advice, psychiatric care or counseling, financial counseling, or routine transportation services (although we can often help our clients coordinate or arrange for these types of services if needed). *

***If you would like a copy of this form, select print BEFORE selecting submit.***

If you have completed your form, please click "Submit" below.

Thank you for taking the time to complete this survey!