I................................. Age :.......Gender :........ Adress :...................................... Hereby authorize (and whomsoever they may designate at staff members) to administer required care as required and to perform the following / Treatment : ................................................................................. and I also authorize care + aide to perform the abhove procedures at my home or any alternative medical set up as deemed approprite by them. I hereby also grant permission and consent for storing of my medical date in the format of secure\electronic medical records. Aggregate and thoroughly anonymized version of this date may be later shared with third parties.
I have been explained that during my tenure as a patient of Shri Sai Nursing Bureau by may be administered medications, prescribed by my physicians, as per their advice, throught oral or other routhes of administration, as is required, under the supervision of my relatives / family. I am fully aware that any treatment / procedure, including the ones that I have to ndergo may have a risk of failure and / or additionally a risk of limiting my fuction, or of incapacitating me. I am also aware that, very rarely, other unforeseen risk or complications not discussed my occue.
I have also been explained that facilities better than those offered Shri Sai Nursing Bureau, by may be available at other places to deal with emergncies arising out of these situations or arising out of the disease it self.
I undestand and appreciate that guarantees or assurance cannot be made as to outcome of procedure of treatment that I may receive or to the result that may be obtained. I certify that no such guarantees have been made towards my treatment and procedures.
I undestand that the care + aide assigned will clinically take care of me. Any non patient care related work like personal work of other family members, fetching medicines, grocery etc.
from outside kitchen work and washing for anything that is not discussed in treatment plan laid out by Coordinator / Medical team.
I also undertake to pay in full, the professional fee / visit charges etc. that are due to Shri Sai Nursing Bureau. I understand that payment to my care + aidenare solely for carrying out the procedures and treatment.
I also undertake that I am not withholding any rlevent information that my care + aide may need for proper conduct of treatment. I have been given the opportunity to ask any question regarding the above, which I Wanted to, ask and have received answer to my satisfaction.
I hereby declare that i have read and understand all information and agree to the terms and conditions mentioned here in after and I have been given all the information sought for, pertaining to the procedures and its risk, alternatives. The Treatment to be given to me will be administered by.........
Signature of Patient : Tel/Mobile No. Date : Signature of Patient Relative : Tel/Mobile No. Date :
I have agreed to make advance payment which will be determined by Shri Sai Nursing Bureau based on the days of agreed visit. upon exhausting of advance amount, I have agreed make further payments with in 3 days.
I here by undertake to make payments for the service availed by me from Shri Sai Nursing Bureau as agreed and I will not insist / ask for further concession / deducation / offers / negotiations etc.
I have declare that I will make payment as agreed and if there is any delay in making payments. Then is at liberty to recover the some along with......% per month interest on the pending amount.
In case of default i payment, Shri Sai Bureau is at liberty to recover the same by initiating appropriate Legel Action.
I hereby agree to expect only the services which are mentioned and explained to me.
I or my family members or attendees undertake to treat the designated or authorised staff members representing Shri Sai Bureau who whould be visiting our premises with deserving diginity and courtesy.