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Dr. Helena Taylor Clinic

Helena Taylor Clinic

Registration Form

Registration Form

registration form

EMERGENCY CONTACT INFORMATION

INSURANCE CARD DETAILS

MEDICAL HISTORY

Do you have or have you had any of the following?

HOW DID YOU HEAR ABOUT US?

GENERAL CONSENT

I authorise Dr. Helena Taylor Clinic and their staff to conduct any assessment, diagnostic xaminations, tests and procedures and to provide any medications, treatment or therapy ecessary to effectively assess and maintain my health, and to assess, diagnose and treat my  llness or injuries. I understand that it is the responsibility of my healthcare providers to xplain the reasons for any particular diagnostic examination, test or procedure, the available reatment options, the common risks, anticipated benefits associated with these options, and alternative courses of treatment.

RELEASE OF PERSONAL AND MEDICAL INFORMATION

I understand that the email address and mobile number that I have provided will be used as a communication tool between Dr. Helena Taylor Clinic and I.

I authorise that my personal medical records may be accessed by relevant HTC staff for the purpose of cross-referral. I further authorise that information from my medical record may be given to physicians in hospitals outside HTC who may be consulted about my care and treatment.

I hereby consent that HTC may release any relevant medical information to third party aboratory or radiology services, as needed, to facilitate testing/referral.

I hereby authorise Dr. Helena Taylor Clinic to provide any information of whatever nature concerning my treatment, including but not limited to current conditions/comorbidities to my insurance carrier or third-party payer, for the purpose of determining benefit entitlement and to process payment, therefore taking responsibility for the financial settlement of my medical bills.

Dr. Helena Taylor Clinic is obliged by federal regulations to submit certain patient information and adhere to NABIDH unification of medical records. I hereby give consent for the use of my information as a statutory requirement. I also acknowledge that this consent
is subject to the laws and jurisdiction of the United Arab Emirates.

I assume full responsibility for all personal property. I understand that valuable may be secured in a safe place upon my request. I hereby release Dr. Helena Taylor Clinic and its staff of any responsibility for valuable and items of personal property that are not secured in a safe place.

Medical test reports requested by the patient/guardian via telephone or e-mail address may be released as an unencrypted report to the e-mail address provided. HTC will not be held responsible for any cost/consequences for providing my unencrypted medical test report to me or to my guardian as requested through a telephone call/ e-mail, after verifying the correctness of below security questions.

The report will be released only on the fulfilment of all the following conditions:
1. The patient/guardian requesting such a report will have to correctly state the e-mail address registered in the system.

Correctly answer any two of the following security questions.

  • Patient’s date of birth
  •  Patient’s Emirates ID number
  •  Details of patient’s last visit

APPOINTMENTS/PACKAGES

Packages must be paid for in full and are valid for 6 months from date of purchase unless specified otherwise. Treatments within a package are subjected to terms within our cancellation policy.

CANCELLATION POLICY

Appointments cancelled within 24 hours of appointment time will not be subject to any charges. Appointments cancelled 12 hours or less may be subject to a charge of 50% of the booked treatment/procedure. Missed appointments may be subject to 100% charge of
the booked treatment/procedure. Patients who have booked packages may lose one of their sessions in accordance with the above.

FINANCIAL AGREEMENT

I, the undersign, understand that Dr Helena Taylor Clinic do not provide direct billing with any insurance provider. I acknowledge and take full responsibility to meet any financial obligations due towards the services I have received at Dr Helena Taylor Clinic. This
includes any amount that may get rejected/declined by the 3rd party payers, insurance companies and other source of payment. Under all given circumstances, I confirm to settle any outstanding due to the clinic. I also understand that estimates are given on approximation & the final bill amount may vary depending on the services used and is liable to compensate the bill in full.

I have read and understood and accept the above terms and conditions, and agree to abide by said requirements herewith towards Dr. Helena Taylor Clinic.

I certify that I have read the details on this registration form and accept all terms and conditions mentioned.