Patient Consent & Acknowledgment Form – Haniawellcare

Patient Information :

Full Name: __________________________
Nationality: __________________________
Passport Number: ____________________
Contact Number: _____________________
Email Address: ______________________
Date: _______________________________

Consent Declaration:

I, the undersigned, voluntarily authorize HaniaWellCare Medical Tourism to:

✅ Review and share my medical reports with partner hospitals and doctors for consultation purposes.

✅ Coordinate appointments, treatment planning, travel assistance, accommodation, and related medical tourism services.

✅ Communicate with healthcare providers on my behalf regarding treatment coordination.

Acknowledgment:

I understand and acknowledge that:

HaniaWellCare is a medical tourism facilitator only and does not directly provide medical treatment or diagnosis.
Final medical decisions are solely the responsibility of the treating doctors and hospitals.
Medical procedures may involve risks, complications, and unpredictable outcomes.
HaniaWellCare does not guarantee treatment success, recovery, or medical results.
I have voluntarily chosen to seek medical treatment through the referred healthcare providers.
I consent to the collection, processing, and sharing of my medical and personal information for treatment coordination purposes.
I have read and understood the Privacy Policy, Medical Disclaimer, and Terms & Conditions of HaniaWellCare.

Patient Declaration :

I confirm that all medical information and documents provided by me are true and accurate to the best of my knowledge.

I voluntarily agree to proceed with the medical tourism coordination services provided by HaniaWellCare.

Patient Signature: _____________________

Name: _______________________________

Date: ________________________________

HaniaWellCare Representative: _____________________

Signature: ____________________________