Your Booking is just few steps away Please enable JavaScript in your browser to complete this form.Patient's Name *FirstLastEmail *Phone number *Full Address *Patient Suffering From / History. *Service Required From *Date (DD-MM-YYYY)Patient Gender *MaleFemalePatient Weight *Any Family / Patient member Suspected / Suffering from COVID 19 (Corona) *YesNoAny recent travel history from overseas or any symptoms of COVID 19(CORONA) Pandemic or quarantine?Terms & Conditions For COVID 19 Positive And Recover Patient. *I AgreeI Disagree (Non COVID Patient)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. 2. If a patient found symptom again due to which our staff will be suspected along with your family then Client needs to be taken care of treatment part for our staff along with all 3. if any member in your family having travelling history due to which if our staff found suspected then also client will be liable for treatment and Client will be arranged COVID test for staff if he or she has symptoms while serving a month at your place 4. The client will help staff to complete his or her treatment in this kind of situation Or Issued Short Term Corona Mediclaim policyRelative Name *FirstLastRelative Contact Number *Required Services. *Female CaretakerMale CaretakerFemale NurseMale NursePhysiotherapistDoctor On Call / Consultation / VisitInfant Care (Baby Care)Medicine / Equipment At HomeWound care / IV / Injection ServicePranyaas parental care servicesDiagnostic Services At HomeAmbulance ServiceCOVID Essential Products like Sanatizer, Mask, Gloves, PPE KIT etc.OtherIf Other Then Please Specify The Required ServicesService Period *24 Hrs Service12 Hrs Service8 Hrs Service2 Hrs ServiceVisit DutyotherIf Other Then Please Specify The Required Service PeriodTerms & Conditions *I AgreeI 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.,Submit
