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Confidential Intake

Share as much as you can. You can save and return to this at any time.

Personal

Full name

Date of birth

Nationality

Phone

Medical overview

Primary condition or diagnosis

Approx. date of diagnosis

Current status

Current care

Current treatments & medications

Treating hospital or physician

Medical records

Upload records, scans, or reports
PDF, JPG or DICOM — drag & drop or browse

Preferences

Preferred destinations

Preferred timeline

I confirm this information is accurate and consent to Kaiyan using it to coordinate my care.

This is a preview. In the live portal, your intake would be encrypted and sent to your Kaiyan coordinator — nothing is stored here.