Medical History Form

Medical History Form

Contact Information
Your Full Name *
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Phone *
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Email *
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Address
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Street Address Address Line 2 Postal / Zip Code Required

State/Region/Province Required City

Required
Country

Physical Informations
What sex were you assigned at birth? *
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Male
Female
Date of Birth (required) *
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dd-MMM-yyyy
Height in cm (required) cm *
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Weight in kg (required) kg *
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Blood Type *
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Emergency Contact
Contact Person in Case of Emergency (Required) *
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Contact Person Phone in Case of Emergency *
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Survey
How did you find MCAN Health? *
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Please specify more; i.e. if Google Search, what did you search for, if Youtube Video which video did you watch, if friend referral, what is the name?
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Terms and Conditions
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MCAN HEALTH Terms & Conditions
These Terms and Conditions set out the terms and conditions about any treatment package you buy from MCAN Sağlık Turizmi Asistans ve Danışmanlık A.Ş.
Please read these Terms and Conditions and the documents referred to below:
Accessing the information and the service provided by the website https://www.mcanhealth.com equals to your acceptance of the terms and conditions listed below.
By accepting our terms and conditions, you confirm that you will be bounded with these Terms and Conditions and you agree to comply with them. MCAN Health has the right to change and modify the Terms and Conditions without any prior notice.
Once you accept the Quote provided to you and fill Medical History Form and based on Medical History Form if you have no health problem for the planned surgery, you will be required to pay a deposit to us and your contract is based on the Terms and Conditions provided here and under the Medical History Form.
Definitions
MCAN Health: Mcan Sağlık Turizmi Asistans ve Danışmanlık A.Ş incorporated as a medical tourism company at Levent Mah. Levent Cad. Alt Zeren Sok, No:5, 34330 Beşiktaş, Istanbul / Turkey and a member of Association of Turkish Travel Agencies with the licence number 10771 and accredited by Ministry of Health of Turkey.
Healthcare Provider: The hospital, private clinic, surgeon, or any other medical professional providing your consultation, examination, medical procedure and care and aftercare.
Treatment Package: The treatment package which can include treatment, accommodation, transfers, city tour and Customer Experience Specialist services depending on patient’s choice.
Treatment: The medical treatment that will be performed in the chosen healthcare provider.
MCAN Health’s Liabilities & Responsibilities
1. Your medical package is determined based on your pictures and test results. Therefore, it might change during physical examination with your healthcare provider.
2. Your treatment package covers all pre-op tests. However, you may be charged additionally for extra tests considered necessary because of a pre-existing condition or your exposure or susceptibility to any condition.
3. Your treatment package includes the assessed number of nights of your stay at the hospital and this number is stated in your Quote and/or Itinerary. In cases where you stay more nights than is stated in your treatment package, the additional nights will be charged to you at the current rates of the hospital.
4. MCAN Health is a medical facilitator company. MCAN Health does not operate or control any healthcare service facility or service rendered by them. By accepting these terms and conditions you agree not to hold MCAN Health responsible for any malpractice or complications caused by your healthcare provider.
The forms at the treatment center constitute a contractual relationship between you and the Healthcare Provider. As a medical facilitator company, MCAN Health facilitates communication with your chosen Healthcare Provider if there is any complication or dissatisfaction. MCAN Health also supports you to get a second opinion regarding your treatment in case of complication or dissatisfaction.
However, we do not hold medical qualifications and shall not be held responsible or liable for any medical procedures provided through your chosen Healthcare Provider.
We shall not be held responsible or liable for any care, treatment, or other services you are provided by the healthcare provider, or for any malpractice claims that may arise directly or indirectly from their advice.
Similarly, we shall not take any responsibility or liability for the complications and dissatisfactions arising from the Healthcare Provider’s treatments. We strongly recommend that you read the Healthcare Provider’s terms and conditions and consent forms carefully prior to proceeding with your treatments.
5. MCAN Health will provide you with all the necessary information about your medical package prior to your journey; it will include:
· The name and contact details of the Healthcare Provider
· The name and contact details of the hotel (if it is included in your medical package)
· The name and contact details of the Customer Experience Specialist (if it is included in your medical package)
· The name and contact details of the driver (If it is included in your medical package)
· Date, time and the locations of the transfers (If it is included in your medical package)
. Date and time of the treatment
. Cost of the treatment package
. Visa and passport requirements
6. MCAN Health is not responsible for any third-party services, such as hotels. MCAN Health is responsible for arranging these services.
Your Responsibilities
1. By accepting these terms and conditions, you agree to share any information about your medical condition.
2. You are responsible for providing appropriate information regarding your medical condition in order to provide you right treatment plan.
3. You are responsible for preparing your travel documents such as passport and visa regarding your treatment offered by healthcare provider. MCAN Health is not responsible for arranging your travel to Turkey for your treatment.
4. By accepting these terms and conditions you give permission to MCAN Health to get your medical records from your healthcare provider and keep that records in case of necessity.
5. In order to get a treatment from MCAN Health’s healthcare provider, you need to make a deposit payment to MCAN Health before you start your journey and you should complete the payment of the whole amount prior to your treatment. You will not get any treatment before you complete your payment.
6. It’s your responsibility to add any type of insurance to your medical package. MCAN Health suggests medical travel insurance on its website and you can proceed with one of them. By accepting this Terms and Conditions, you accept your insurance obligation.
Cancellation
1. Based on Article 2.1, if your treatment plan changes as a result of your actual physical examination by your doctor/surgeon or because of your test results, you have the option not to proceed. In those circumstances, you will receive a refund after deduction of the costs related to tests and consultations and such from your total package amount.
Please be aware that MCAN Health is not responsible for refunding your accommodation, travel, and transfer costs as those arrangements are not made by MCAN Health but by or through other third-party providers, that are not controlled or operated by MCAN Health. If you want to proceed with the new treatment plan, then you will receive a revised price quotation.
If the treatment plan changes, the duration of stay may also change. MCAN Health takes no responsibility for this and cannot be held liable for the lack of arrangement or organisation of the extra days stayed or the additional cost of the extra stay.
2-.Deposit is the reservation fee and cannot be refunded in any circumstances. Deposit validity is for 6 months after the deposit is paid. In force majeure conditions such as earthquake, pandemic, the pregnancy, the validity is extended for another 6 months or until the medical availability of the patient to have the treatment.
Medical Examination
MCAN Health reminds you that all kinds of surgery/treatment carry certain medical risks; the risks associated with cosmetic surgery also include dissatisfaction with the results. You and the surgeon/professional have to agree about the anticipated outcome of your surgery/treatment so that your expectations of the results will be realistic and reasonable.
Any medical or surgical advice provided through the MCAN Health website, e-mail documents, any messages are accurate to the best of MCAN Health’s knowledge. However, it is your responsibility that they are once more discussed at a face-to-face consultation with your Surgeon prior to your treatment. Therefor please never hesitate to ask your surgeon all you want to know before undergoing surgical treatment.
Aftercare
You will have a certain number of controls after your surgery. One will be at the hospital and the other will be before you will return to your country. Your after-care instructions will be provided to you by your surgeon.
You are obliged to follow the after-care instructions. If any indication of complications occurs after you have returned to your country, we will assist you by asking your pictures, test results, any doctor report that you received in your home country and we will deliver them to your surgeon to follow your case, provide an opinion and determine possible next steps for post-operative treatment.
If you require revision or corrective treatment and if your surgeon confirms and accepts that you require revision or corrective surgery, the surgeon will underwrite the cost of the treatment. You will only have to bear the cost of hospital (excluding the surgeon), travel, accommodation, transfers and sustenance in that case.
The clinic/hospital will give you aftercare instructions and advice. Should you not follow these instructions and repercussions would arise because of the lack of care, the hospital and surgeon can not be held responsible.
There is no possibility for a refund by your hospital, surgeon, or MCAN Health. MCAN Health also suggests in its website medical travel insurance that covers surgery/treatment expenses in your home country in the case of any complication. Having insurance is your responsibility.
Feedbacks and Reviews
MCAN Health aims to provide excellent service. MCAN Health is looking for feedback from its patients in order to improve its services provided that the reviews are sincere, genuine, helpful, and directly related to MCAN Health services. MCAN Health is an intermediary to provide quality treatments at affordable prices. However, MCAN Health can not be held responsible for the services given by healthcare providers and their action.
By accepting these Terms and Conditions, you agree not to attack or criticise MCAN Health or any of its employee publicly (review websites, social media networks, blogs, public forums etc.) regarding Medical Service Provider’s (doctor, medical personnel, hospital) treatment and services and the services of the hotel. In case of breaching this clause, you have to remove and take down the content immediately upon our assessment. If the content remains, in part or a whole, you agree to pay 5,000 EUR to MCAN Health as damages.
Confidentiality and Data Protection
1. MCAN Health is responsible for the safe keeping of your personal information in a strictly confidential manner. MCAN Health will not disclose your data, records, or information without your consent and will only share it with medical staff.
2. To guarantee your privacy, MCAN Health maintains all patient information in compliance with Turkish Laws regarding the release and disclosure of personal health information. Your anonymous before and after pictures can be used for demonstrative purposes and might be presented only to show possible results from various procedures. We will not sell or rent your personal information to third parties.
By accepting these terms and conditions you permit MCAN Health to use your the before after pictures of your treatment in an anonymous way to improve our site, to provide better customer service.
Jurisdiction
In case of disputes arising from this contract, the Parties accept the authority of Court and Execution Directorates of Istanbul.

I accept the Terms and Conditions.

Medical History Form

Contact Information

Physical Informations

Medical Background

Medications & Allergies

Emergency Contact

Survey

MCAN HEALTH Terms & Conditions

Definitions

MCAN Health’s Liabilities & Responsibilities

Your Responsibilities

Cancellation

Medical Examination

Aftercare

Feedbacks and Reviews

Confidentiality and Data Protection

Jurisdiction

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