CA1 PATIENT MEDICAL PROFILE (STRIPE)

PATIENT MEDICAL PROFILE (STRIPE)
Personal Medical History (Step 1)
(Please fill out to the best of your ability)
Full Name*
Email Address*
example@cubaeal.com
Phone Number*
Skype Handle (If available)
Example@Cubaheal.com
Date of Birth*

MonthDayYear
Weight **
In Kilograms
Height *
In Centimeters
Citizenship *
Citizenship
Place of Residence*
Place of Residence
Decision Maker's Name in the Event you Become Incapable of Understanding a Proposed Treatment or Become Unable to Communicate your Wishes Regarding Care*
Telephone Number of Unattended Decision Maker *
Describe the Exact Medical Condition (If unknown, type N/A)*
Requested Treatment*
Preferred Treatment Start Date*

MonthDayYear
Physician's Name

PrefixFirst NameLast Name
Physician's Phone Number

Area CodePhone Number
Physician's Name

PrefixFirst NameLast Name
Physician's Phone Number

Area CodePhone Number
Dentist's Name

PrefixFirst NameLast Name
Dentist Phone Number

Area CodePhone Number
Eye Doctor's Name

PrefixFirst NameLast Name
Eye Doctor's Phone Number

Area CodePhone Number
Other

PrefixFirst NameLast Name
Other Phone Number

Area CodePhone Number
Your current medical condition:*
Treatment Received (In details)*
History of prescription and non-prescription medicine*
Medications you are currently taking*
Drug sensitivity and allergies (describe):*
Have you ever been told you had one of the following?
Lung disorder *

YesNo
High blood pressure *

YesNo
Heart trouble *

YesNo
Nervous disorder*

YesNo
Disease of the kidney*

YesNo
Malaria*

YesNo
Any form of cancer*

YesNo
Hepatitis*

YesNo
Alzheimer / Dementia*

YesNo
Disease or disorder of the digestive tract*

YesNo
Diabetes*

YesNo
Arthritis*

YesNo
Disease or disorder of the blood?(Describe / If not applicable, please enter "None")**
Any physical defect or deformity? (Describe / If not applicable, please enter "None")*
Any vision or hearing disorder?(Describe / If not applicable, please enter "None")*
Any life-threatening conditions? (Describe / If not applicable, please enter "None")*
Any contagious disease?(Describe / If not applicable, please enter "None")*
Have you been treated by a physician or been disabled or hospitalized during the last year? (Describe / If not applicable, please enter "None")*
Have you had or been advised to have a surgical operation within the last five years? (Describe / If not applicable, please enter "None")*
Date of last physical:

MonthDayYear
Date of last tetanus shot:

MonthDayYear
Family history (list important medical problems of your parents):
Father:*
Mother*
Any other special medical information:*
Do you require a wheelchair?*

YesNo
Meal and diet preference:

Non meat mealsNon dairy meals
Religious adhering meals:

KosherHalalOther
Doctor/ physician/ Nursing/ support staff preference:

MaleFemaleNo preference
Translation Services:

YesNo
If yes, please chose your language
Medical reports uploads
Upload file

Upload a File

Cancelof
Upload file 2

Upload a File

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* If the file(s) size is large, please use either zipfile or RAR applications

* If you need to forward X-Ray images, please take a mobile picture for such images and forward them to us using the "Upload File" option

MEDICAL DISCLAIMER AND WAIVER (Step 2)
I agree to save CubaHeal Medical Tourism, Inc. harmless of all legal, financial, and any and all other liability that includes agents, employees, successors and assigns, and the respective heirs, personal representatives, affiliates, successors and assigns of CubaHeal Medical Tourism, Inc. and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not named, from any and all claims, demands, damages, actions, causes of actions or suits of any kind or nature whatsoever, which have or may hereafter have arisen out of or in any way relate to any and all injuries and damages of any and every kind, to both person and property, and also any and all injuries and damages that may develop in the future, as a result of or in any way relating to the services provided by CubaHeal Medical Tourism, Inc.
I understand and agree that CubaHeal Medical Tourism, Inc. does not provide medical advice or medical treatment.
I understand and agree that CubaHeal Medical Tourism, Inc. facilitates only and uniquely my travel to and my stay in Cuba for medical purposes that have received the consent of my personal physician.
I acknowledge that prior to engaging the services provided by CubaHeal Medical Tourism, Inc. I have consulted with my personal physician and any medical specialists my personal physician has recommended.
This consent shall be governed by the laws of the province of Ontario

I have read and fully understand this Waiver and I acknowledge that I have received an Independent Legal Opinion with respect to the content, the meaning and the implications and risks I assume by executing this Disclaimer.
Acknowledged and agreed to this*

MonthDayYear
Full Name*
Witness Full Name*

AUTHORIZATION FOR HOSPITAL and/or MEDICAL CENTER TREATMENT - Step 3
Full Name*

PrefixFirst NameLast Name
Date and /Time of Signing

MonthDayYear
Witness to Signature Full Name

PrefixFirst NameLast Name
Authorized Representative’s Name and Relationship (if patient unable to sign)

PrefixFirst NameLast Name
1. CONSENT FOR TREATMENT: I, the undersigned, request and authorize the Hospital and all its physicians, surgeons, technicians, nurses, and other qualified personnel, whether employed directly by the Hospital or brought in on a consulting basis, to provide any medical/surgical treatment, diagnostic tests and hospital care which the attending physician or designee(s) may deem necessary or beneficial for my health. I understand that the results of any treatments, tests or care cannot be guaranteed. I also understand that I have the right to refuse any drugs, treatment, or procedures to the extent permitted by law. I understand that medical, nursing, and other health care personnel in training may be observing and participating actively in my care under the supervision of authorized personnel. I hereby give my consent to such observations and/or participation.
2. RELEASE OF RESPONSIBILITY FOR PERSONAL VALUABLES: I have been made aware that the Hospital provides special facilities for the safekeeping of valuables. I release the Hospital from any responsibility for the loss or damage to any valuable possession (including valuables brought into me by other persons) that I choose to keep in my personal possession and do not deposit with the Hospital for safekeeping.
3. RELEASE OF INFORMATION: To obtain payment for services, I authorize my medical facilitator (CubaHeal Medical Tourism Inc.) to furnish and release to my insurance carrier(s) or their representatives insuring the patient named, any or all portions of my medical record which may be necessary for completion of my patient care insurance claims. I understand that billing agencies for specialized services such as radiology, emergency services, and anesthesia will also receive information necessary for billing.
4. While in the Republic of Cuba, I authorize my medical facilitator’s (CubaHeal Medical Tourism Inc.) field members or management in the Republic of Cuba, to be responsible for, and handle all, invoicing issues relating to my treatment and medical care. This includes the signing off on all medical care invoices.
5. I authorize my medical facilitator to be responsible for payments relating to additional medical services’ cost not included in my treatment program including, but not limited to, on-location medical evaluation, medical complications, emergency services, surgical or otherwise. I understand my medical facilitator would invoice me separately upon my safe return to my home country.
6. I authorize the release of copies or summaries of my medical record to any health care facility or home care provider to which I may be transferred or referred. I further authorize release of my medical information to any physician involved in providing my care. I hereby release the Hospital from all legal liability that may arise from the release of the information requested and provided. A photocopy of this authorization shall be as binding as the original.
7. ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY: I request that payment of authorized benefits be made on my behalf and do hereby authorize payment directly to Cubaheal Medical Tourism Inc. and/or Cuban medical authorities of any benefits that otherwise would be payable directly to me for this period of hospitalization or treatment. I understand that I am financially responsible to the hospital and/or physician for charges not covered by this authorization.

WHAT IS NEXT? - Step 4
The next step will be to forward your medical information (Including your uploaded medical files) to the Cuban Medical Authorities in order for them to make a determination if there are any treatment programs available to your specific medical case, and what are the best medical options available for you. This process usually takes between 10-14 business days excluding weekends and Cuban national holidays.

Upon receipt of the Cuban medical authorities’ final decision, we will correspond with you via email to guide you through the third and final step which will involve the careful planning of the following:
- Cost of your treatment;
- Your preferred treatment start date;
- Planning the trip for you and your companion (Should you wish to);
- Planning and reserving your hospital/ hotel accommodation (Including your meal plan and transportation from and to) for you and your companion (Should you wish to);
- Planning other desired services such as translation and entertainment during your stay in Cuba
Important Update:

As of August 1, 2015, CubaHeal introduces an essential step forward in enhancing our service quality and efficiency. We will require a $200.00 CAD initial deposit for submitting medical profiles to the Cuban Medical Authorities for comprehensive assessment. This upfront contribution will be seamlessly integrated into the total cost of your selected treatment program(s), ensuring a smooth and transparent financial process.

This measure is born from our commitment to uphold the integrity and dedication of the Cuban Medical Authorities. Their meticulous effort in evaluating each case, crafting personalized treatment plans, and allocating specific treatment slots demands recognition and respect. Unfortunately, a trend of applicants seeking complimentary consultation and diagnosis, without proceeding to treatment, has prompted us to implement this policy. Such practices not only disregard the professional labor involved but also extend the wait times for other patients desperately needing timely care and intervention.

Why This Matters to You:
- Value and Respect for Professional Expertise: Your deposit acknowledges the valuable time and expertise the Cuban Medical Authorities invest in meticulously reviewing and planning for each patient’s care.
- Enhanced Access and Efficiency: By discouraging non-serious applications, we ensure quicker access and reduced waiting times for genuine patients, streamlining the pathway to recovery and healing.
Transparent and Fair Financial Policies:

Full Integration into Treatment Costs: Should your application progress to an approved treatment, this deposit will be deducted from the overall cost, effectively rendering the initial assessment phase at no additional cost to you.

Refund Policy for Non-Approval: In the rare instance where treatment is not advised due to the nature of the condition, CubaHeal Medical Tourism Inc. guarantees a refund of the entire deposit minus any bank wire transfer fees, ensuring fairness and transparency.

Commitment to Your Health Decision: If after receiving approval, you decide not to proceed with the treatment, the deposit will serve as a fee for the comprehensive consultation provided. This policy supports the sustainability of offering such detailed evaluations and maintaining the high standard of care CubaHeal is known for.

Payment Process Notice:

For your convenience, CubaHeal utilizes the payment processing services of our trusted sister company, CHMT Canada Inc. Please expect to see CHMT Canada Inc. listed as the beneficiary on your credit card statement, reflecting our transparent and secure financial operations.

We thank you for understanding the necessity of this policy, designed to enhance the quality and efficiency of the healthcare journey we offer. CubaHeal remains dedicated to facilitating access to exceptional medical care in Cuba, with respect and fairness at the heart of our approach.

Sincerely yours,

CubaHeal Administration Department

Payment

Submission$200.00CAD

Total $0.00CAD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Signature*

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