Thank you for your interest in Medera Global Health for your healthcare needs. Please briefly describe the patient’s ophthalmology concern and upload any available medical reports or imaging records. Based on the information provided, an MGH advisor will follow up with you regarding possible next steps, including remote ophthalmology specialist review, in-person consultation in China, further examination, or treatment coordination.

Please Note: This form is intended for non-emergency appointment requests from international patients. If you are experiencing a medical emergency, please contact your local emergency services or go to the nearest emergency department immediately.

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Your Name *

First

Last

Email Address *

Phone Number *

Country / Region of Residence *

Please enter where you are currently located, such as London, UK; Toronto, Canada; or Shanghai, China.

Passport Issuing Country / Region *

Who are you inquiring for? *— Select —SelfFamily / CaregiversFriendOther

If you selected Other, please specify.

Health Information

Gender *— Select —MaleFemaleOtherPrefer not to say

Please enter the patient’s gender.

If you selected Other, please specify.

Date of Birth *

Please enter the patient’s age.

What eye or vision concerns is the patient currently experiencing? *

Please briefly describe the patient’s current eye or vision problem, such as blurred or reduced vision, distorted vision, eye pain, redness, flashes or floaters, double vision, difficulty seeing at night, or problems after a previous eye surgery.

How long has the patient had these symptoms or eye problems? *

For example: several days, 3 months, several years, since an eye injury, since a previous surgery, or recently getting worse.

Has the patient already received a diagnosis from an eye doctor? *— Select —YesNoNot sure

Gender Phone or

If yes, please provide detailed information.

Has the patient previously received any eye surgery or treatment? *— Select —YesNoNot sure

If yes, please provide detailed information.

Please briefly describe any previous eye surgery, laser treatment, eye injections, or other treatment, including the approximate date if known.

Does the patient already have eye examination, imaging, or other medical records? *— Select —YesNoNot sure

Please upload medical reports or related records

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

If available, please upload eye examination reports, diagnosis reports, OCT scans, fundus photographs, visual field tests, corneal topography or tomography, ultrasound scans, CT or MRI scans, previous surgery records, or other relevant ophthalmology records.

Service Preferences

What is your preferred contact method? *

• Email
• Phone
• WhatsApp

What type of support are you currently looking for? *

• I would like a remote ophthalmology specialist second opinion first
• I would like to visit China for in-person consultation, examination, or treatment
• I am considering both options
• I am not sure yet and would like to speak with an advisor first

When do you plan to travel to China?

If you already have an estimated timeframe, please enter it here, such as August 2026, within the next 1–3 months, or not decided yet.

What is your estimated budget for your health check or healthcare journey in China?

Additional notes

Please add any other information you would like us to know.

Privacy Policy *

• I have read and agree to the Privacy Policy, and I understand that this form is for initial inquiry only. *

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