Padma Care - Insider Medical Service and Advocacy Program

Thanks for becoming a Padma Care Member. This online format is intended to make filling this form easier for you. It should take between 5-10 minutes max.

Best wishes, the Padma Care team
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PADMA CARE MEDICAL CONCIERGE

NEW MEMBER SIGNUP FORM
Your Name (New Member)*

First NameLast Name
Gender
Date of Birth

DayMonthYear
In format DD/MM/YYYY
Place of Birth (Country)
This is required for patient registration (National law)
Mobile Phone / Whatsapp Contact*
Please use format +62 (country code)
Email Address*
example@example.com
Your Home Address
City
or Town or Kabupaten or Kecamatan
Country
Zip Postal Code
Not Required, but can be helpful
Your registered address (if different)
or landmarks to guide us on a home visit
A note on Forms in general. We know they stink - but the better information we have from the start, the better we can help you quickly if you ever get sick. Only a bit more to go.
Padma Care is designed to work with a credit card on file. We accept both local and international credit cards for your convenience. This avoids the common frustration of having to ask for prepayment for medical services and allows us to evaluate and analyze charges for validity prior to processing them.

Complete information about our services can be found here: Terms of Service
By Checking this Box you agree to the terms of our Service Agreement including charges for medical bills and service charges

Yes
Emergency Contact & Family Information

We hope that you are never in a situation where you cannot make your wishes known, but it does happen and as a 'first call' provider of your medical care we want to be aligned with your intentions in this unlikely event.
Partner Name

First NameLast Name
Relationship to Member
Email (if different)
example@example.com
Location
(If they live in a different place)
Partner Phone (Whatsapp)
Any other contact number
Potentially a child's phone
Other household residents that may access service
Please include ages for reference
Preparing to set appointments for you

Every hospital in this country will ask for an official photo ID before allowing us to book an appointment - your passport is the easiest way forward. Please fill details below.
Passport Number
This is required for patient registration in our systems
Please share a copy of your passport

Any appointment we make for you at a hospital will require this information. It makes it easier if we have it on file from the beginning (so you don't have to dig it out in an emergency).
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Customizing your service

Padma Care is about more than saving you money, we want to build a relationship with you and deliver you healthcare information in the format that works best for you.
How should our team address you when we reach out think your health advisor?
We prefer to address you by your first name to keep things casual, and also to avoid the occasional odd power dynamic - of course we are happy to address you however you'd like.
What kind of information style works best for you?
ex. summary only, medium and balanced, all the details please
When do you prefer us to update you about medical things?
Do you have a preference of the gender of your caregiver
What is your biggest concern we can focus on alleviating?
For Relocating Members

We allow you to select a future date for the start of your service. To complete sign-up you will need to authorize a credit card, but if you fill this field your service will not begin until the date below and your card will also not be charged until then.
Subscription Start Date

DayMonthYear
Now you can choose the date you want your service to begin. We won't charge you until you move, but you can tick another thing off your list by signing up early.
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PADMA CARE MEDICAL CONCIERGE

Emergency Contact & Family Information

Preparing to set appointments for you

Customizing your service

For Relocating Members