* Not Applicable to Malleshwaram Hospital (MNSH)
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(* Passport details is a mandatory requirement for proof of identity for Foreign National)

Consent & Declaration

I, the undersigned, declare that the above information provided by me are true to the best of my knowledge and hereby provide my consent to the Manipal Hospital to provide Medical Care, Treatment, Conduct Investigations and Diagnostic Procedures necessary for the above mentioned individual by Medical Staff at Manipal Hospital.

I, also understand that Manipal Hospital will not be responsible for any loss, damage or theft of any Personal Property/Belongings of Me/Patient/Visitors within the Hospital Premises. Including Patients rooms and Parking area. I agree to follow all the rules and regulations of Hospital and clear all the expenses incurred for My/Patient treatment on time as per the Terms and Conditions of Manipal Hospital, Bengaluru.

I would like to recieve my/Patient reports by Email: Yes No & Hospital Info Alert: Yes No

Relationship with patient (if consent provided on behalf of the patient).

I hereby give my consent and authorize Manipal Hospitals to process, store , use, disclose my personal or sensitive information /data collected as per Manipal Privacy policy.

Place:       Date & Time:

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