Your Service Booking Information
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Name *
Email Id *
Mobile Number *
Full Address With Flat no. And Building name *
City *
Pincode *
Patient Suffering From / History. *
Service Required From. *
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/
DD
/
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Patient Gender *
Patient Weight *
Patient Age *
Any Family / Patient member Suspected / Suffering from COVID 19 (Corona) *
Any recent travel history from overseas or any symptoms of COVID 19(CORONA) Pandemic or quarantine?
Terms & Conditions For COVID 19 Positive And  Recover  Patient. *
1. The client will be taken care of all safety measure for staff & also patient which include mask sanitizer gloves hand wash, PPE kit or green gown etc.                                                                                                                                                                                                        
Relative Name *
Alternate Relative Contact No (should be different from Phone number field) *
Required Services. *
Required
Service Period *
Required
Minimum Day Service Required *
Hospital Name Or Treating Doctor Name (If Any)
How Did You Hear About Us?
eg. Google, LinkedIn, Mail, Facebook either If Referred by person please specify the person name or Referral Code.
Terms & Conditions *
I have read and agree to the Terms and Conditions above information filled is correct and I authorize AYUSHYA HEALTHCARE representative to contact me.                                                                              
 1) I hereby authorize AYUSHYA HEALTHCARE and whomsoever they may designate as Professional to check, administer or perform the all or either of the following services:
           A) Basic Home Health Aides and Care for 12 hours or 24 Hours.
           B) Skilled Nursing Care, ICU or Non – ICU.
           C) Elderly Care Service at Home.
           D) Intervention and Physiotherapy (Short Term Service)                                                                  
2) Do not hire or staff directly, if noted like that than AYUSHYA HEALTHCARE will not co-operate in any matter and will stop services for the client as well as for the staff.                                                                  
3) Not to disclose the charges being paid to the company with the Staff.,                                            
4) Our Staff will not take care of any Household work like Mopping, Washing utensils etc. other than patient care.  
5)The PATIENT/RELATIVES is responsible to protect his/her valuables and keep them in safe custody during period of visit by AYUSHYA HEALTHCARE staff. AYUSHYA HEALTHCARE will not be responsible for any such theft or misappropriation and will not pay any claims pertaining to such unauthorized use, theft or misappropriation.  
6)The PATIENT/RELATIVES  understand that the AYUSHYA HEALTHCARE Staff are neither authorized to accept, have custody of or have the use of cash, credit or debit cards, bank cards, Cheques or other valuables belonging to PATIENT or family members and nor are they to be paid any kind of cash by PATIENT/ RELATIVE. 
7) In case of an emergency, go to the hospital if the patient is in a critical condition. 
8) The rent for equipment is based on a monthly basis, not a day-by-day basis, and there are no refunds once the equipment is delivered to the client.      
9)If the duration of your services is less than 5 days, our services fee will be raised by Rs 200 per day on agreed charges.
10) Surcharge: This will be applicable during festivals and national holidays as an incentive for the staff.  The surcharge fee will be Rs.200/- per day 
(for new services acquired during festivals and the national holidays season)                                                                                                                                                                                                                                       
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