Patient Consent & Declaration Form
Please read this declaration carefully. It governs the role of HEALINDIA MEDITOURISM® as a facilitator and outlines patient responsibilities, financial obligations and liability.
Print, fill, sign and return to your patient coordinator.
1. Patient Information
- • Full Name
- • Date of Birth
- • Nationality
- • Passport Number
- • Contact Number
- • Email Address
- • Address
2. Medical Information
- • Medical Condition / Diagnosis
- • Proposed Treatment / Procedure
- • Treating Hospital (if known)
3. Declaration of Understanding
I, the undersigned, hereby declare and confirm that:
Medical Role & Responsibility
- I understand that HEALINDIA MEDITOURISM®, a unit of Santos King Tours & Travels Pvt Ltd, acts solely as a medical travel facilitator.
- I acknowledge that they do not provide medical advice, diagnosis or treatment.
- All medical decisions, procedures and outcomes are the responsibility of the treating hospital and doctors.
Accuracy of Information
- I confirm that all medical records and personal information provided by me are true, complete and accurate.
- I understand that non-disclosure or incorrect information may affect treatment outcomes.
Treatment Risks & Complications
- I understand that all medical procedures carry inherent risks and may involve complications.
- I accept that any additional treatment, extended hospital stay or emergency care due to complications will incur extra charges, which I agree to bear.
Financial Responsibility
- I acknowledge that the treatment cost estimates are indicative and may vary depending on actual medical requirements.
- I agree to make payments directly to the hospital or authorized entities as advised.
- I understand that HEALINDIA MEDITOURISM® is not responsible for medical billing or hospital charges.
Insurance & Emergency Coverage
- I confirm that I have been advised to obtain comprehensive medical and travel insurance.
- I understand that emergency medical evacuation (including air ambulance) is not included and must be covered by me or my insurance provider.
Travel & Health Advisory Compliance
- I confirm that I have read and understood the Health Advisory guidelines.
- I agree to follow all medical, travel and recovery instructions before, during and after treatment.
Liability Waiver
I agree that HEALINDIA MEDITOURISM® and Santos King Tours & Travels Pvt Ltd shall not be held liable for:
- Medical outcomes or complications
- Delays or cancellation of treatment
- Travel-related issues beyond their control
- Any unforeseen medical emergencies
Consent for Coordination
- I authorize HEALINDIA MEDITOURISM® to share my medical reports with hospitals and doctors for the purpose of treatment coordination and evaluation.
4. Consent Confirmation
I have read, understood and voluntarily agree to all the terms and conditions mentioned above.
5. Attendant / Guardian (if applicable)
Important Notice
HEALINDIA MEDITOURISM®, a unit of Santos King Tours & Travels Pvt Ltd, operates strictly as a facilitator connecting patients with healthcare providers. Medical care, treatment decisions and outcomes are the sole responsibility of the respective hospitals and medical professionals.