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."
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Medical History Form - Orthopaedic Surgery
 
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
Country
Telephone
Fax
Email Address*
Occupation
Sport and hobbies
Selected Surgical Procedure
Why are you considering this procedure?
Give details of the procedure you are requesting?
Current Medication
Medical History
Do you have any recent medical records Yes No
If so, please give Doctor's name
Contact telephone no for this Doctor
Allergies
Have you consulted a surgeon for this procedure? Give details
Are currently consulting a Physiologist or Physiatrist Yes No
If so, have you consulted in view of your intention to have the above mentioned surgery
 Yes No
Do you drink or smoke? Give Details Yes No
Cigarettes / Day
Drinks / Day
Have you or your family ever had difficulties with General Anaesthetic? Yes No
Are you prone to KELIODS or poor scaring? Yes No
Have you ever been ANAEMIC? Yes No
Do you have ASTHMA or LUNG DISEASE? ASTHMA Yes No
LUNG DISEASE Yes No
Do you have HIGH BLOOD PRESSURE? 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? Yes No
Do you take Warfarin, Aspirin or Arnica
Joint Affected
Underlying diagnosis of joint pathology
Give details Osteoarthritis and Rheumatoid
Can you forward X-rays ? Yes No
Family history of thrombosis
Please name the surgeon
When would you consider travelling to India?
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW
Terms & Conditions
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Accommodation
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Cost Estimate:
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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:
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Accommodation
Personal Assistant to accompany you to all your medical appointments and surgery
Transport for return airport transfers and medical appointments.
Detailed Itinerary.


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


Payment Terms:
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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.


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Surgery - Terms and Conditions
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Medical Evaluation:
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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:
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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:
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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:
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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 require you to email or post past medical records and X-rays to:

Med Access India
A/3/9/5, Millennium Towers, Sector 9, Sanpada,
Navi Mumbai, Pin Code 400 075, India
Please be assured that all electronic data received is treated with the strictest confidentiality.
  

 
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