Patient Consent

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.

Download Consent Form (PDF)

Print, fill, sign and return to your patient coordinator.

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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.

Patient Name: __________________________

Signature: ______________________________

Date: ___________________________________

5. Attendant / Guardian (if applicable)

Name: ___________________________________

Relationship: ____________________________