Personal Medical History 
(Please fill out to the best of your ability)

Have you ever been told you had one of the following?

Family history (list important medical problems of your parents):

Medical reports uploads 

* 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

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.

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.

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 NOTICE:

1. Starting August 1, 2015, please be advised that CubaHeal will request a $135.00 CAD initial deposit for the submission of medical profiles to the Cuban Medical Authorities for assessment which will be deducted from the total cost of the treatment program(s). This is due to the fact that it has come to our attention that a number of applicants who have been granted approval for treatment in Cuba were only interested in receiving free consultation and diagnosis. In our opinion, this is an unfair conduct since:
   The Cuban Medical Authorities have taken the time to review and assess the patient’s condition, develop an appropriate program and reserve a spot for the patient to be treated in, and
   
   
2. The allocated spot is reserved to the specific patient for an assigned number of days creating a longer waiting period for other patients awaiting urgent care or treatments.
   
   
3. Kindly be Aware, CubaHeal utilizes its payment processing services via rgainc.ca, our sister company. In your credit card statement, you would notice the name rgainc.ca as the beneficiary.

Please take note of the following:

1. Should the Cuban Medical Authorities approve a patient's treatment, Cubaheal Medical Tourism Inc. will subtract the initial deposit from the total cost of the treatment;
   
   
2. Should the Cuban Medical Authorities refuse a treatment for a patient due to the extent of his/ her condition, CubaHeal Medical Tourism Inc. will refund the full amount less the wiring fees if the payment was made by a bank wire; and
   
   
3. If a patient is approved by the Cuban medical authorities but decides not to accept the offered treatment Program, CubaHeal Medical Tourism Inc. will consider said initial deposit as a consultation fee and will not refund it.

Sincerely yours,

CubaHeal Administration Department