Amara New Patient Enrollment Form

Amara Home Visit Form
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Your details
Name*
Telephone Number*
Please enter a valid phone number.
Email*
example@example.com
Home Address*

Street Address

Block / House Number

CityState / Province

Postal / Zip Code
Update details (if needed)
If the patient is a child:
Relationship to child
Person with legal authority to consent present at visit?

YesNo
Communication & consent
How would you like to be addressed?*
We default to Sir and Madam if left blank.
Preferred contact method*

WhatsAppTelephoneEmailEncrypted email (egress)SignalTelegramOther
If other contact method, please specify:
I acknowledge some channels may be compromised and not secure (HIPAA/GDPR-compliant) and accept the associated risks with sharing confidential medical records, consenting to their use for my communications.
Next of kin / emergency contact to be contacted in the event of an emergency or if we are unable to reach you: *

First nameLast name
Next of kin telephone number
Please enter a valid phone number.
Next of kin email
example@example.com
Billing & authorization
Billing terms
- Tests/treatments/medications/referrals are billed separately.
- Tests proceed after payment; if time-critical, we may proceed on verbal authorisation and invoice immediately.
- Please find the Consultation rates in the price list below.
- Same-day cancellations incur a call-out fee.
- Price list: attached inside confirmation email. Itemised invoice/receipt provided.
Please confirm:*

I acknowledge and authorise the billing terms above
Invoice recipient

MyselfNext of kinOther
Name (if other recipient)
Email (if other recipient)
Invoice recipient email
ID and Health Insurance

Please upload/email your:
Identification (Emirates ID or passport)*

Cancelof
Health insurance card

Cancelof
Health insurance policy with details of cover.

Cancelof
Clinical information
Reason for visit (optional but encouraged)
Medical Emergencies (if any of the following is present, please call 998 / your local emergency number first):
- Chest pain / heart attack
- Severe breathlessness / choking
- Weakness on one side / facial droop / signs of stroke
- Uncontrolled bleeding / severe injuries
- High fever with lethargy / drowsiness
- Seizure / shaking or jerking due to a fit
- Rapid swelling of lips, mouth, throat or tongue
Please confirm:*

I confirm none of the above apply.
• Medications & supplements: Please keep medications and supplements ready in anticipation of the doctor’s arrival.

• Onboarding consultations: Please share previous reports and records with the doctor during the visit or share them with us in advance (concierge@amarahealthcare.com)

• Chaperone: For your comfort, a chaperone is welcome to be present. This may be a member of your family or, where available, a member of our team.

• Privacy notice: We retain your information in accordance with applicable law and our Privacy Notice. For sensitive documents, we default to Egress unless you have instructed otherwise.
Should be Empty:

Amara Home Visit Form

Your details

Communication & consent

Billing & authorization

Clinical information