The above information is true to the best of my knowledge. I understand that withholding / concealing the above information is unethical and against the interests of the global population fighting the COVID 19 pandemic.
During this lockdown in the wake of the current COVID 19 pandemic, I have come to the hospital by myself voluntarily to avail Emergency Treatment / Treatment. If I am an asymptomatic carrier or an undiagnosed patient with COVID 19, I suspect it may endanger doctors and hospital staff, and therefore, it is my responsibility to take appropriate precautions and to follow the protocols prescribed by Government of India and other healthcare institutions.
Despite all efforts taken by Hospital / Doctors / Staff of Doctors to prevent COVID 19 which is explained to me, I understand that I may get an infection from the hospital or from a doctor, and I will take all precautions to prevent this from happening, but I will not at hold doctors and hospital staff accountable if such infection occurs to me or my accompanying persons.
If I hide by facts and relevant details and because of my intentional or unintentional behaviour or action OR if any Healthcare personnel gets infected, I will be held responsible and appropriate legal actions shall be taken against me and my attendant.
I agree that all the above information provided by me is true and accurate. I hereby give my consent to Lifeberries Healthcare to conduct the required Diagnostic tests on me.
4th Floor, 403-A, Town Square, Above Dorabjee’s, VIP Airport Road, Behind Symbiosis College, Viman Nagar, Pune – 411 014
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© 2020 Lifeberries Healthcare - Diagnostics | Dental Clinic - Viman Nagar
Mon – Sat 8 AM – 9 PMSun : 8 AM – 6 PM
020 2663 3223 | 9890830301
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