Thank you for your interest in becoming a mentee!

Please complete all fields and submit the request below. We will contact you within 2 business days.

 

PERSONAL INFORMATION
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Patient's Name: *
Patient's Name:
Address: *
Address:
Cell Phone: *
Cell Phone:
Other:
Other:
May we text you to set up an initial phone call? *
ABOUT YOU
Please provide us with your primary diagnosis (the condition that requires the most resources and care) and anything else you wish to share at this time
DEMOGRAPHICAL INFORMATION
For nondiscrimination reporting purposes, only
Date of Birth: *
Date of Birth:
MENTOR PREFERENCES
Please list your preferences as they pertain to your mentor
Do you have a specific person in mind whom you'd like to be your mentor? *
How did you hear about MedMentor?
Please select all that apply
I acknowledge that by clicking the Submit button below, I am agreeing to exchange limited personal health information about myself with MedMentor. Further, I understand that basic information about myself will be anonymously (without name or street address) shared with a potential medmentor to aid in determining a suitable match. Once a match is determined, my identity and other relevant information about me, including my health information, will be shared with my medmentor to the extent it aids in facilitating a successful match. *
Today's Date: *
Today's Date:
By clicking on the submit button you are authorizing MedMentor to add you to their mailing list and contact you by either mail, phone and/or email.