Forms

FORM A   

 

FOR MEDICLUB MEMBERSHIP AND INDIA MEDICAL VISIT - REGISTRATION:

 

Full Name             

 

Date of Birth                                                     Age

 

Address                 

 

City                           

 

Zip Code        

 

Country       

 

Telephone No.                                                   (with international code)

 

Brief statement about the present illness                Optional for members          

 

Payment made on                                               Amount:                Reference  

 

FOR INDIA MEDICAL VISIT:  (Club members to submit at the time of their visit)

                   

PHASE I

 

Medical history:

                 

All medical documents including Scans, Cardiogram, Pathological reports and bservations by the Consultants for the Surgeon's evaluation here.

 

Interaction                        

 

In the normal course you can contact us through email.  However, we will give you the name of the Surgeon, telephone number and Email ID for contact purposes if necessary.

 

Feedback                         

 

The surgeon will decide the course of treatment or surgery based on the above.  The following are the important factors.

                                           

1.      Cost of Surgery

2.      Duration of hospitalization

3.      Hotel arrangements before surgery.

4.      Post operative stay in India for checkup after            surgery/treatment.

5.      Cost of medicine, clinical tests, etc.

 

Cost Estimate                     

 

We will furnish a tentative cost estimate based on the above factors, Preferences in accommodation, choice of place for recuperation,  holidaying in India, etc.

 

We will mail a separate form for the purpose of Cost Estimates, terms of payment and other terms & conditions.             

 

PHASE II 

 

On receipt of approval of the cost estimates by you and the bank transfer of Service charges, your first consultation with the Surgeon is scheduled.

Your will be received at the airport and taken to Hotel.

The final confirmation of the cost estimate will be given after physical examination and further evaluation by the Surgeon.

Terms of Payment:

Service Charges to Mediclub India is payable by bank transfer.  Deposits required to be made for booking of medical and other services is payable to Mediclub India by bank transfer. Balance payable will be directly settled by you to the Hospital or other service providers as per their invoices, by Credit Card or Travelers Check.

Follow up consultations will be arranged and recovery process is reviewed as desired.

A good English speaking assistant will accompany with you for all your appointments, surgery and local travel and transport facilities will be provided.