PADMA CARE MEDICAL CONCIERGE

Thanks for your interest in becoming a Padma Care Member. This online format is intended to make filling this form easier for you. As an alternative you are welcome to print, fill, scan and return the .pdf (just follow the QR code listed).

Feedback always welcome as we strive to improve our services - which include our new customer signup flow as well!

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 if you ever get sick.
Coordination of Payments
Padma Care is designed to work with a credit card on file. We will always send you prior notification of any charges to be processed several days in advance via email and/or WhatsApp - depending on your preferences. 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. Alternatively, we have to keep a deposit balance on account in anticipation of service costs.
By Checking this Box you agree to the terms of our Service Agreement including charges for medical bills and service charges

Yes

Alternative to Card on File
Account Holder Name As on Account
Bank Name
Account Number

We have improved our policy and now send you a separate link (via our partner Xendit) to safeguard your credit card information. Please review the service agreement carefully as our service charges you fees incurred after our internal validation and vetting process. We will always send you a copy of the invoice and receipt upon successful completion of a transaction. If a charge fails to settle, we reserve the right to stop service and cancel membership (we will provide you notice and try to revise your payment first).
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 dependents that may access service
Please include ages for reference
Preparing to set appointments for you
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).
Cancelof
Customizing your service
How should our team address you when we reach out think your health advisor?
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?
When do you prefer to schedule medical appointments?
Do you have a preference of the gender of your caregiver
Should be Empty:

PADMA CARE MEDICAL CONCIERGE

Coordination of Payments

Emergency Contact & Family Information

Preparing to set appointments for you

Customizing your service