Consent Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Your Name (Patient Relative) *FirstLast Patient Your Mob No. (Patient Relative) *Your Email. (Patient Relative) *Procare's Coordinating Manager Name Mr RizwanMr ShrikantPrem GuptaOtherPatient Name *FirstLastPatient Adress *Gender *MaleFemaleOthersAge *Height *Weight *Mental Status *AggressiveCalmNormalMobility Status *WalkingBedriddenExpected Start Date * *Agreed Service Cost (write in Digit ) *Family Emergency Contact *Preferred Staff Gender *MaleFemaleStaff Religious Preference *HunduMuslimNo PreferenceServices Required *Nursing ServiceAttendant ServiceNanny ServiceDoctor VisitNurse VisitAttendant VisitPhysio VisitShifts *12 hrs Day12 hrs Night12 hrs - 12 hrs Day and Night24 hrs at home1-2 hrs VisitA) Medical Conditon Briefpatient is on oxygenTracheostomy careOn Ventilator Or BipapRT feedPEG FeedColostomy BagPICC LineNJ tubeDAMA/LAMA statusChemo-portB ) Medical Conditon Brief- Compulsory *I Agree Terms & Conditions * *Tick The Check Box1. PARTIES This Master Home Healthcare Service Agreement ('Agreement') is entered into between Procare Health Advisors Private Limited ('Procare' / 'Company') and the undersigned Patient / Client / Authorized Representative ('Client'). By clicking 'I AGREE' and/or digitally signing this Agreement, the Client confirms acceptance and agrees to be legally bound. 2. SERVICE CATEGORY SELECTION The Client confirms selection of applicable services: Nursing Services; Non-Medical Attendant Services; ICU / Critical Care at Home; Equipment Rental. Only selected services shall apply. 3. GENERAL TERMS Services are provided on a best-effort basis. Procare does not guarantee cure, recovery, or specific medical outcomes. Home healthcare involves inherent risks including deterioration, complications, or death. Liability shall arise only in cases of proven gross negligence established by a competent court. Promoters and directors shall not be personally liable unless personal misconduct is proven. 4. NURSING SERVICES (If Selected) Nursing personnel operate within scope of qualification. Nurses shall not independently alter prescriptions without written physician instruction. Clinical decisions remain with the treating doctor. 5. NON-MEDICAL ATTENDANT SERVICES (If Selected) Attendants provide mobility, hygiene, feeding, and daily living support. They are not medical professionals and shall not administer injections, alter medications, interpret reports, or perform invasive procedures. 6. ICU / HIGH-RISK CARE (If Selected) Home ICU is not equivalent to hospital ICU infrastructure. Equipment failure, power disruption, or emergency delays beyond control shall not create liability. Natural disease progression shall not be attributed to negligence unless legally proven. 7. EQUIPMENT RENTAL (If Selected) All equipment remains property of Procare. Client shall not tamper, relocate, or attempt repairs. Damage, misuse, or theft shall be chargeable to Client. 8. CLIENT RESPONSIBILITIES Client agrees to provide accurate medical history, share valid prescriptions, maintain safe premises, ensure stable power supply, make timely payments, and treat staff with dignity. 9. PAYMENT TERMS & SERVICE SUSPENSION All payments shall be made as per invoice schedule and before the due date. Time of payment is essential. In case of delay, Procare may suspend or withdraw services without prior notice and without liability. Outstanding dues shall remain payable. Continued service despite delay shall not constitute waiver. Legal recovery costs shall be recoverable from Client. 10. PAYMENT CONFIDENTIALITY All financial discussions shall be strictly between Client and Procare management. Client shall not discuss salary, margins, or billing structure with staff. 11. NON-POACHING & NON-SOLICITATION Client shall not directly or indirectly hire or engage any staff introduced by Procare during service period and for 12 months thereafter. 12. CONSEQUENCES OF POACHING Unauthorized engagement shall attract minimum three months of average billing or agreed fixed amount, whichever is higher. Direct payment to staff does not absolve Client liability. 13. LIQUIDATED DAMAGES The above amount represents a genuine pre-estimate of loss and shall be payable within seven (7) days of invoice issuance. 14. INDEMNITY Client shall indemnify Procare, its directors, promoters, and employees from false allegations, unfounded complaints, defamation, or third-party claims. 15. LIMITATION OF LIABILITY Total liability shall not exceed service fees paid for the disputed period. No indirect, consequential, emotional, or punitive damages shall be claimable. 16. STAFF SAFETY Procare may immediately withdraw staff in case of harassment, unsafe environment, illegal demand, or non-payment. 17. DISPUTE RESOLUTION Disputes shall first undergo internal resolution. If unresolved, arbitration under the Arbitration and Conciliation Act, 1996 shall apply. Jurisdiction: Mumbai, Maharashtra. 18. DIGITAL VALIDITY Electronic acceptance via 'I AGREE' constitutes legally binding consent under the Information Technology Act, 2000. Digital logs, timestamps, IP records, and OTP authentication shall constitute valid evidence of acceptance. CLIENT DIGITAL CONFIRMATION ■ I understand risks associated with home healthcare. ■ I understand distinction between Nursing and Attendant services. ■ I agree to Non-Poaching and Payment Confidentiality clauses. ■ I accept Limitation of Liability provisions. ■ I agree toSubmit