Medical Treatment Center India, Medical Center India
Med Access India
 
"After three years of pain, difficulty walking, and an inability to work, I have finally entered a new hopeful and exciting chapter in my life It would not have been possible without MedAccess India's help and guidnce."
                       More..
Pay here
 

Medical History Form - Infertility Treatment

 

Thank you for visiting the Med Access web site.

Med Access will forward your medical details to your selected surgeon who will reply with his basic clinical evaluation and any relevant details as soon as possible.

Please Note: For this enquiry to reach us you must provide a valid email address.

Name*
Surname
Date of Birth
Weight and Height W
H
Postal Address
Telephone
Fax
Email Address*
Occupation
Hobbies and Interests and sport
Have you had Infertility Treatment before?
What Infertility tests have you and your partner had where, when and what are the results?
What Infertility treatment have you had?
If you are currently consulting a Psychiatrist or Psychologist Have you discussed your intention of having the above mentioned surgery Yes No
Have you ever been treated for psychiatric illness? This includes depression.
If so, what treatment have you been on in terms of anti-depressants, sleeping tablets, anxiolytics (anti anxiety)
How long have you been taking this treatment?
 Yes No
Would it be possible to get a comprehensive report from your physician/psychiatrist in terms of your condition? Yes No
Have you suffered from previous deep vein thrombosis, i.e. blood clots, developing in the leg following long air flights, long hospital stays, etc?
If so, when was this and what treatment were you prescribed and for how long
 Yes No
Have you ever abused drugs or any substance?
If so, What and for how long and when did you stop.
 Yes No
Current and prescribed Medication you are taking
Past Medical History that needs mention
Allergies
Give details of the procedure you are requesting?
Have you consulted a surgeon for this procedure? If so, what was the plastic surgeon name and what was his plan of operation?
Do you drink or smoke? Give Details Yes No
Cigarettes / Day
Drinks / Day
Have you or your family ever had difficulties with General Anaesthetic? If so, please advise of any complications. Yes No
Are you prone to KELIODS or poor scaring? Yes No
Have you ever been ANAEMIC? If so, how was it treated and have you ever had a Blood Transfusion? Yes No
Should a blood transfusion be necessary, would there be any reasons at all why you would refuse it?
Do you have ASTHMA or LUNG DISEASE? ASTHMA Yes No
LUNG DISEASE Yes No
Do you have HIGH BLOOD PRESSURE? If so, what treatment are you taking and are you well controlled? Yes No
Do you have any known HEART problems? Yes No
Have you ever been JAUNDICED? Yes No
Are you on the "PILL" or any other HORMONE? Yes No
Do you or any relatives have DIABETES? If so, please specify Yes No
Please name the surgeon you have selected
When would you consider travelling to India?
Would you like to correspond with past clients? Yes No
   
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW
Terms & Conditions
------------------------------
--------------------------------------

Accommodation
--------------------------------------


Cost Estimate:
--------------------------------------
The cost estimate for recuperation is quoted in Indian Rupees subject to exchange rate fluctuations. Certain terms and Conditions apply.

Any bookings confirmed and not taken up will be subject to cancellation fees.


Includes:
--------------------------------------
Accommodation
Personal Assistant to accompany you to all your medical appointments and surgery
Transport for return airport transfers and medical appointments.
Detailed Itinerary.


Excludes:
--------------------------------------
Tour Options.
Transport for all additional outings
Rejuvenation treatment.
.Additional expenses not specified.
Meals


Payment Terms:
--------------------------------------
Non-Refundable Deposit required securing your booking.
Deposit to be invoiced and paid to Med Access via bank Transfer - as indicated on the invoice - and will be deducted from the daily room rate charged.
Balance payable when you check in on arrival.
Payment can be made via valid Credit Card or Travelers Cheque or Cash.


--------------------------------------
Surgery - Terms and Conditions
--------------------------------------


Medical Evaluation:
--------------------------------------
The fee quoted will be confirmed after further medical evaluation by the surgeon.

We will arrange for Initial Clinical Evaluation by the surgeon after receiving the Medical History Form and recent Photographs /X-Ray's / CT scan / MRI Scan's / Echocardiogram / Angiogram / Pathological Reports or a summary of observations on them as per the treatment/ procedure requirements

We encourage you to ask questions using email or the telephone.

Both you and the surgeon are under no obligation until after your pre operative consultation.

Med Access reminds you that all surgeries carry risks, have limitations which could include disappointment with the results.

You should agree about the anticipated outcome of your surgery and concur about your expectations of the results.

You should discuss alternative treatments and thoroughly understand the risk of the procedures
If any dispute may arise the surgeon is only liable if litigation takes place in India under Indian Law.
Any medical or surgical advice provided through the Med Access web site and service, even if intended to be accurate to the best of our knowledge, should be discussed with the Surgeon.
Always seek advice from your Surgeon before embarking on any treatment, medication or therapy.


Cost Estimate - Surgery:
--------------------------------------
The cost estimate is to be confirmed by the surgeon at your pre-op consultation prior to surgery.
The cost estimate is subject to exchange rate fluctuations, certain terms and Conditions apply


Includes:
--------------------------------------
The cost is all-inclusive whilst in India for selected procedure: The surgeon, specialist anesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication, pre and postoperative consultations and non-refundable administration fee, for the selected procedures.

Medical evaluation, Email correspondence and Telephonic consultations.
Pre and Post operative instructions for your selected procedures.
Detailed Itinerary for pre and post operative consultations.


Excludes:
Any additional medical expenses that might have incurred for the safety of your health as a result of unforeseen complications Ð please discuss with the surgeon.

Insurance.

Additional procedures.


Payment Terms:
--------------------------------------
Non Refundable Administration Fee charged as a deposit to secure your booking.
Deposit payable to Med Access via bank transfer as indicated on the invoice and will be deducted from the agreed cost estimate.
Balance of the fee payable directly to the surgeon at your pre operative consultation
Payment can be made via valid Credit Card orTravellers Cheque or Cash
I have read the terms and conditions above: Yes No
After sending this form we request that you also send us a close up photograph of the body area you are requesting the procedure for. This will assist further medical evaluation by the surgeon.
 
Please be assured that all electronic data received is treated with the strictest confidentiality.
Thank you for taking the time to complete this profile.
 
 
Medical Tourism India, Medical Tourism In India
Cosmetic Surgery, Cosmetic Surgery India
Orthopedic surgery India, Obesity surgery India, Neurosurgery India, India IVF
Medical Tourism Guide, Medical Tourism Company India
 
Medical History Forms India
 
Partner with us - Hospitals in India
 
Download Med Access Presentation
 
Medical Tourism | Orthopedic Surgery | Obesity Surgery | Cosmetic Surgery | Neurosurgery | Medical Travel | Affordable Cosmetic Surgery | Healthcare In India | India Hospitals | Infertility Treatment | Cardiothoracic Surgery | Medical Tourism India | Eye Treatment Services | Medical Travel India | Best Doctors India
Copyright @ 2008 MedAccess. All Rights Reserved. Design by: Ensure  
Maintain by BSSI