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Service Booking Form
Date (DD-MM-YYYY)
Any recent travel history from overseas or any symptoms of COVID 19(CORONA) Pandemic or quarantine?
1. The client will be taken care of all safety measure for staff & also patient which include mask sanitizer gloves hand wash, green gown etc.
How Did You Hear About Us? eg. Google, LinkedIn, Mail, Facebook either If Referred by person please specify the person name or Referral Code.
I have read and agree to the Terms and Conditions above information filled is correct and i authorize Ayushya 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 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 Care Giver. 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. 5)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.
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