In Need Of Diagnosis, Inc. (INOD) Help Request Form

In Need Of Diagnosis, Inc. (INOD) does not diagnose but it is sometimes possible to identify an unexplored option that may lead to help. Please provide the following information and email, fax or mail to In Need Of Diagnosis, Inc. (INOD): Email: Help@Inod.org; Fax: 407-898-4234; Mail: PO Box 536456, Orlando, FL 32853. Note: If you are contacting INOD on behalf of someone else, please enter your information at the beginning of the form and enter their information below, in the place provided.

Your Name *

First
Last
Your Spouse's Name

First
Last
Your Email Address *
Alternate Email Address *
Primary Phone *
Alternate Phone
Street Address
City *
State *
Zip Code *
Age *
Sex
How did you hear about INOD?
Are you the person who is undiagnosed?

If you are contacting INOD on behalf of another person, please provide this information:

What is your relationship with that person?
What is their name?

First
Last
What is their sex?
What is their age?
What is the primary problem?
How long have you had the problem that is undiagnosed?
Is there something that triggered the problem as an accident, surgery, medications, move to new environment ? ? ?
May we share your information with people we feel might be of help? *
 Yes 
 No 
INOD strives to provide helpful information but needs feedback to know if it was helpful. Do you agree to provide feedback?
 I agree to provide feedback 
Please provide details of the problem and what steps have you taken to find help (please do not abbreviate medical conditions or tests unless such abbreviations are commonly used):
This website is provided as an information service only. It is not intended to provide medical advice. Every effort has been made to ensure that the information on this website is correct, but In Need Of Diagnosis, Inc. (INOD) does not accept any responsibility for action or omission based on inadvertently incorrect information posted on this website by In Need Of Diagnosis, Inc (INOD) or by support groups. It is strongly recommended that persons wishing to use information obtained on this website, first consult their medical practitioner.
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Disclaimer

This website is provided as an information service only. It is not intended to provide medical advice. Every effort has been made to ensure that the information on this website is correct, but In Need Of Diagnosis, Inc (INOD) does not accept any responsibility for action or omission based on inadvertently incorrect information posted on this website by In Need Of Diagnosis, Inc (INOD) or by support groups. It is strongly recommended that persons wishing to use information obtained on this website, first consult their medical practitioner.
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