Amara New Patient Enrollment Form

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How would you prefer our team to address you. By default we address our patients as Sir or Madam.*

Email Address

example@example.com

Date of Birth*

DayMonthYear

Would you like all emails to be encrypted? (we use egress)*

How do you wish to pay for your medical treatment?*

Please upload or take a photo of your insurance card. Please also upload your health insurance policy or email to concierge@amarahealthcare.com from the email you have shared above.

Personal identification (passport, driver's license or government-issued identification): Please attach to this form below, or alternatively please email to concierge@amarahealthcare.com from the email address you have shared above.

Next Of Kin Details: *

First NameLast Name

Telephone Number:*

Email*

Relationship

In case of an emergency if you are uncontactable, do you provide consent for your next of kin to be contacted and for relevant clinical information to be divulged?*

YesNo

In order to keep communications as convenient as possible, would you prefer to be contacted via:*

Point Of Contact (optional):

If "other" was selected, please kindly specify:

First NameLast Name

Telephone Number:

My designated point of contact may be involved in all medical arrangements and handling of clinic and referral letters as may be required.

NHS/alternative GP details:

For UK residents, it is strongly recommended to have an NHS GP registered.

I consent / do not consent to my medical information being shared with my regular GP if I am not contactable. Please select below accordingly.

Patient Signature*

Date*

Date

Do you have any allergies to medications or other agents?*

If yes, please kindly specify the allergens.

Optional: To ensure the correct health screens are taking place in a timely fashion, please advise when the following have last taken place:
(We can also go through this information when we speak)

Skin Check.

OGD (endoscopy of the food pipe and stomach).

Colonoscopy.

Male:

Prostate check (by MRI or blood test).

Female:

Gynae ultrasound.

Mammogram.

Smear test.

Medications

Please provide a list of medications including the dose and strength (in the following section, shared images will also suffice).*

It is our policy to have a chaperone for all intimate examinations. Please advise us before any consultation whether this is required.
It is also our policy that all paediatric examinations must be carried out in the presence of a parent or guardian.

Do you require a chaperone before this consultation?

Please tick the following as you find appropriate:*

I consent to being contacted by un-encrypted email and/or telephone and/or WhatsApp Business and/or SMS to discuss management plans, diagnoses and to disclose results. I accept the risk associated with receiving messages received by the above means.I understand that, whilst the health screening program is designed to make diagnoses at an early stage, a risk remains of missed diagnoses. I take responsibility to discuss results as follow up or with my personal Doctor and to present at an early stage should new symptoms or concerns develop.I understand that incidental findings occur, and whilst these may be deemed to be benign at a very early stage, they may develop to serious pathology. I accept the responsibility of conveying these results to my regular Doctor for appropriate monitoring and investigations to take place.I accept the responsibility to have follow-up investigations for any abnormalities identified and recommendations made in the health screen report.I understand that if another party is settling my bill, or if I wish to use private medical insurance, I am responsible for settling all charges which remain outstanding.I understand that if I wish to utilise private medical insurance, I should contact my insurer before my consultation(s) to check the terms of the policy, particularly the level and type of outpatient cover I may have, including any reimbursement limits on individual consultation fees.I understand that Amara Healthcare is unable to charge insurance companies directly and the claim’s process is between myself and my insurer(s) so that Amara Healthcare may be focused entirely on managing my health.I understand there will be a 5% processing fee on the payments made for appointments external to the clinic on my behalf. For complex schedules to be arranged, additional administrative charges by the medical operations team may be applicable.I accept that prior to appointments, a fee structure is shared and that as fees change, a new letter will then be shared.

Patient Signature*

Date*

Date

Information Sharing Consent Form using WhatsApp Business and or text messages.

Amara Healthcare adheres to 2018 General Data Protection (GDPR) regulations. However, there may be circumstances when it would be more convenient for you, as our client to communicate with us and to receive information from us via WhatsApp Business service, text message, or other messaging services of your choice.

At present, we cannot guarantee patient confidentiality through the use of aforementioned messaging services. Within the clinic, all staff are legally bound to maintain confidentiality through their professional registration and by the company’s Non-Disclosure agreement.

If you would like to communicate with us and receive personal information and data from us via either WhatsApp Business, text message or other messaging services, we are happy to do this. We must ask that you sign the attached consent form giving us the permission to do so.

I full name* , give my permission for Amara Healthcare to share personal information with me (or my point of contact) through WhatsApp Business or Text message using the number noted on this form.

Statement of Consent:

• I understand that personal information is held about me and that there is a risk of information being leaked when using the above - mentioned platforms.

• I have had the opportunity to discuss the implications and risks of sharing information this way about me.

DATE:*

CLIENT SIGNATURE:*

Patient Enrollment Form

HEALTH