Service Agreement Form

Dr.Ethix's Wellnezzone Home Nursing Services
No:111, D Block, 1st main road, Annanagar East
Chennai - 600 102, T.N., India,
Contact : 95000 73479 / 95977 10333
Website : www.welnez.org

Service Agreement

Patient / Client Name

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Age

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Address

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Service Start Date

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Relationship (if signing on behalf)

Registration Fee ($)

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Tariff Amount ($)

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Terms and Conditions

I agree that I have received Patient Rights & Responsibility and I am aware of the same.

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I agree that Wellnezzone is a Home Healthcare company and in case of any emergency Wellnezzone will support in shifting patient from home to hospital and cannot provide emergency care at home. Wellnezzone is a Home Healthcare company has restrictions on the ability to provide emergency care at home, I agree to follow any guidelines and advice given by the medical monitoring team which may include shifting to the hospital.

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I agree that Wellnezzone Staff is a qualified nursing professional and will provide nursing care as required by the patient and will not be asked to or forced to do any kind of housekeeping and/or domestic work that is unrelated with the patient's nursing requirement.

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I agree to treat the staff with respect and dignity and understand that any physical/mental/verbal or chemical abuse will lead to automatic cancellation of service.

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I understand that in case of an emergency there may not be enough time for the medical officer to come to the place of service and will abide by any telephonic advice given in the best interest of the patient based on the feedback and the condition shared on the phone. I also understand that this will not be a substitute for a proper physical examination.

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