1. I have decided to be treated as patient at Fakeeh Care, I consent voluntarily to undergo routine tests and treatments as part of the primary care.
2. I agree to give my treating physicians at Fakeeh Care the right to decide any kind of care and treatment for me as they feel necessary in emergency situations.
3. I have been informed that I have the right to identify a person or persons to be informed about my medical condition and to be aware about the detailed information in my medical record, also to take decisions concerning any treatment, procedure, or surgical intervention on my behalf during my stay, if my general or mental condition does not enable me to share in the decision-making process, and request & obtain medical reports on my behalf upon their request, so I authorize the following person(s) to be my designee(s)
4. I agree as a patient's designee / legally authorized person on behalf of Mr. / Mrs.: to provide him / her with all the necessary treatment and procedures, and I will bear all responsibilities and legal liabilities concerning my signature on this consent form.
5. I understand that I should be cooperative with Fakeeh Care administration, employees, and the responsible health care team that will be chosen by the attending physician which includes not only the treating physicians, their assistants and nurses, but also: technicians, dieticians, social workers, and any professionally competent person officially designated by Fakeeh Care to care for me / my patient in order to obtain the optimum medical care. I also agree to respect Fakeeh Care policies and regulations.
6. I understand Fakeeh Care data privacy policy and agree to the use and retention of my personal data for the purposes of my treatment as per the MOH rules and regulations.
7. I authorize Fakeeh Care to release any required information and send copies of any relevant documents from my medical records to my insurance providers, other sources of payment or Ministry of Health, as well as any legal, governmental authority requiring such information.
8. I authorize Fakeeh Care for the use of personal means of communication including the addresses and mobile number for the purpose of sending marketing or awareness materials.
9. I agree to provide Fakeeh Care with all necessary documents which will be requested upon my admission, including the approval of my company/insurance company, as regards to financial reimbursements concerning my treatment and hospital stay
10. I am aware of the Fakeeh Care price list, and I agree with. Also I declare the awareness of Fakeeh Care regulations and procedures for knowing the approximate estimated cost for my treatment and hospital accommodation upon my request before getting the service and during my admission.
11. I pledge to preserve and take care of any Fakeeh Care property and equipment in different areas and patient's room, and I will pay in cash any damages or missing items that I may cause to Fakeeh Care property.
12. I agree not to keep valuables, jewellery and other personal belongings or cash in the room. I know that Fakeeh Care will not be held accountable for loss of any such valuables, and I know that I have no right to request any financial compensations for my losses, so long as they are in my possession and not kept in the Fakeeh Care safe box.
13. I agree to comply with the standing Fakeeh Care rules and regulations that prohibit smoking in all Fakeeh Care premises / bringing in food, beverages, or personal furnishings (linens, rugs, pillows, etc.), personal electrical or electronic devices from outside and to comply with Fakeeh Care standards related to infection control program, door decoration standards, which are designed for patient and staff safety, visiting hours and with the Hospital's policy for companions and care givers.
14. I know that the failure to evacuate the room within one hour "of financial discharge", will make me incur additional financial charges for extra stay as per Fakeeh Care regulation
15. I know that I should have only one medical record, so I pledge in case if I have more than one record to inform the registration staff in the reception to merge them.
16. I had been informed that I have to bring all documents related to my medical condition from outside Fakeeh Care to be scanned in the reception, in order to be part of my medical record.
I acknowledge that I have read, understood, and agreed to all the above-mentioned statements, and I have signed this consent expressing my full acceptance. I have received a copy from Fakeeh Care Bill of patient Rights and Responsibilities, and I have been informed that I have the right to receive a copy of this signed consent form upon my request.
