PATIENT REGISTRATION & CONSENT FORM

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PATIENT REGISTRATION & CONSENT FORM FORM

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Step 1 of 2

PATIENT NAME

First

Last

GUARDIAN /CUSTODIAN’s NAME:

First

Last

MOBILE NO

ADDRESS WHERE SERVICE IS REQUIRED

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

NO SERVICES

GUARDIAN /CUSTODIAN’s PRESENT ADDRESS

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

DOB

GENDER

Male
Female

HEIGHT

WEIGHT

NAME

First

Last

RELATION

MOBILE NO

DIAGNOSIS

Present treating Doctor’s Name

Preferred hospital Name in case of emergency

SERVICES RENDERED

PER DAY

CONSENT FOR HOME CARE

I,hereby solemnly affirm that the information provided above is true to the best of my knowledge, and no part of it is false or withheld. I understand that in the event any part of the information provided is found to be incorrect or false, services may be terminated immediately without prior notice.

I further affirm that should there be any changes to my address, I will inform the hospital within two days of such change. I hereby declare that I am over 18 years old and am providing all my personal and medical information to Keysmore Technologies Pvt Ltd. I consent to the company contacting me via phone, text, email, or any other communication channels.

I understand and am fully aware of the risks associated with home-based follow-up treatment and medical care related to my current medical condition. These risks have been explained to me in detail by the company coordinator, and I have been given sufficient opportunity to ask questions.I voluntarily grant my informed consent to receive home-based follow-up treatment and medical care from Keysmore Technologies Pvt Ltd through its qualified and trained medical and paramedical staff.

I acknowledge that the patient’s attendant will be responsible for 24/7 food, lodging, and care of the staff, and will be accountable for all cash and belongings at the home. The company will not be liable for any theft, loss of valuables, or any claims pertaining to such incidents.Furthermore, I agree that neither the patient nor the attendant will hire or engage any staff of the company directly. In such cases, the company reserves the right to withdraw services immediately, without notice, and no refund will be processed for the attendant.

Signature is not required for this consent. By providing this information, you acknowledge your agreement to the terms outlined above.

Date

PLACE