Title
Patient Name:
Patient Surname:
Company Name:
Sector:
Your position in the field of business:
Telephone:
Email:
Web:
Address:
Country:
City:
Age:
Are you currently receiving any treatment from a doctor/hospital/clinic? Yes No
Yes No
If yes, please provide details:
Are you currently taking any prescribed medicines? Yes No
Do you carry a medical warning card? Yes No
Are you pregnant ? Yes No
Are you allergic to any food, medicines or substances? E.g. latex or penicillin.? Yes No
Do you suffer with eczema? Yes No
Do you suffer with bronchitis, asthma or chest conditions? Yes No
Do you suffer from fainting attacks, giddiness, blackouts or epilepsy? Yes No
Do you suffer from heart problems, angina, blood pressure problems or stroke? Yes No
Are you diabetic or is anyone in your family? Yes No
Do you suffer from arthritis? Yes No
Do you suffer from bruising or persistent bleeding following injury, tooth extraction or surgery Yes No
Do you have any infectious diseases? Yes No
Do you have rheumatic fever or chorea? Yes No
Do you have liver disease or kidney disease? Yes No
Do you have any other serious illness? Yes No
Has your blood ever been refused by the blood transfusion service ? Yes No
Have you ever had a bad reaction to local or general anaesthetic ? Yes No
Have you had a joint replacement or other implant ? Yes No
Have you had heart surgery ? Yes No
Do you smoke ? Yes No
If so, please give approximate number of cigarettes per week:
If so, please give approximate number of cigarettes per week: Terms and Conditions 1.HealthcareTour directs tourist patient who comes from abroad to Turkey’s best hospitals for treatment and provides them best services during their treatment. 2.HealthcareTour will be welcoming you at the airport ,transferring to hotel and hospital. 3.HealthcareTour can get visa letter or patients own medical report from hospital that mıgh be needed for use visa application. 4.HealthcareTour of patients gets free counseling service 7 days 24 hours, when they are in Turkey, during the treatments . 5. Patient information sent reports to be shared only with the hospital and will be kept hidden HealthcareTour file this information in any way will not be shared with any third party. 6. HealthcareTour will not be held responsible for any problems between the hospital and the patient but to HealthcareTour patients will be provided referral to other hospital that contracted HealthcareTour with the condition to pay the difference in wage. 7. HealthcareTour cannot accept responsibility for you missing aircraft due to late arrival of connecting aircraft or for late check-in at the airport. You are responsible for the provision of all necessary valid documents, including passports and visas. 8. Healthcaretour accepts no liability for loss or injury of any kind including death or injury caused by the negligence of the surgeons, hospital/clinic or its staff. Payment Terms 9.Upon an agreement being made for a booking, an Initial Deposit is required before your departure. If you do not pay this in full before departure, we reserve the right to cancel your booking, and cancellation charges may apply. The balance of the Treatment Package cost is payable at the clinic/hospital prior to the treatment. Initial deposit will be %10 of total Treatment Package cost which will be paid 10. Your treatment is a contract between you and the hospital and/or surgeon undertaking the treatment. We hold no medical qualifications and are neither responsible nor liable for any medical procedures. We can be arranged video conference from your hospital doctor according to your request after initial payment completed. 11. If the patient did not do pre-payment to Healthcaretour Bank account, hospital, hotel and other bookings will not be made. 12.HealthcareTour contacts with the best successful hospital in Turkey according to patient medical report or patient health complaint then will be sending their price of treatment. HealthcareTour is not responsible additional health services during the treatment of patient. However, cost of treatment to be added the patient’s knowledge and its approval. 13.HealthcareTour will be responsible upon patients request patient accommodation, hotel and transfers during the treatment and also be arranging city tour after treatment in order to improving patient psychologically that added to in the package price.