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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,
I would like to receive Self/Patient reports by Email
I would like to receive Hospital Info Alerts reports by Email
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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
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International Federation for Surgery of Obesity and Metabolic disorders.
Obesity Surgery Society of India.
Association of Surgeons of India.
Indian Association of Gastrointestinal Endosurgeons.
Association of Minimal Access Surgeons of India.
Field of Expertise
Bariatric (weight loss) and Metabolic surgery
Laparoscopic surgery for Gall stones, appendix and hernias -Abdominal wall reconstruction for complex Hernias
Advanced Laparoscopic surgeries
GI and colorectal surgeries
Laser surgery for piles, fissures, fistula and pilonidal sinus
Breast (benign and cancer) surgery
Laparoscopic gynaecology surgeries
Languages Spoken
English
Hindi
Marathi
Awards & Achievements
Organising member of the Robosurge Conference 2015 at Sir Gangaram Hospital, New Delhi.
Organising member of the VTECon 2013 at Leela Kempinski, Gurgaon.
Delegate at 33rd Annual Conference Of MASICON February 2011, Mumbai.
Training programme on Simulated Techniques In Proximate Staplers at Ethicon Institute Of Surgical Education August 2010, Mumbai.
Best Paper Presentation- Diaphragmatic Hernia” at the 189th Research Meeting of Medical Research Centre Of Bombay Hospital.
1st position in Medi-Quiz at Inter-collegiate level, 2007.
2nd position in P.S.M. Quiz at Inter-collegiate level, 2006.
Talks & Publications
Bhardwaj AM, Trehan KK, Sharma V. Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: Our patient series over a period of 10 years. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 18].
Case report – Tuberculous splenic abscess” Bombay Hospital Index-Journal- Volume 54, No. 1, January 2012.
Dissertation to the Maharashtra University Of Health Sciences - `` Case Study – Pseudocyst Of Pancreas”.
Languages Spoken
English
Hindi
Marathi
Fellowship & Membership
Royal College of Surgeons of England.
American College of Surgeons.
International Federation for Surgery of Obesity and Metabolic disorders.
Obesity Surgery Society of India.
Association of Surgeons of India.
Indian Association of Gastrointestinal Endosurgeons.
Association of Minimal Access Surgeons of India.
Field of Expertise
Bariatric (weight loss) and Metabolic surgery
Laparoscopic surgery for Gall stones, appendix and hernias -Abdominal wall reconstruction for complex Hernias
Advanced Laparoscopic surgeries
GI and colorectal surgeries
Laser surgery for piles, fissures, fistula and pilonidal sinus
Breast (benign and cancer) surgery
Laparoscopic gynaecology surgeries
Awards & Achievements
Organising member of the Robosurge Conference 2015 at Sir Gangaram Hospital, New Delhi.
Organising member of the VTECon 2013 at Leela Kempinski, Gurgaon.
Delegate at 33rd Annual Conference Of MASICON February 2011, Mumbai.
Training programme on Simulated Techniques In Proximate Staplers at Ethicon Institute Of Surgical Education August 2010, Mumbai.
Best Paper Presentation- Diaphragmatic Hernia” at the 189th Research Meeting of Medical Research Centre Of Bombay Hospital.
1st position in Medi-Quiz at Inter-collegiate level, 2007.
2nd position in P.S.M. Quiz at Inter-collegiate level, 2006.
Talks & Publications
Bhardwaj AM, Trehan KK, Sharma V. Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: Our patient series over a period of 10 years. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 18].
Case report – Tuberculous splenic abscess” Bombay Hospital Index-Journal- Volume 54, No. 1, January 2012.
Dissertation to the Maharashtra University Of Health Sciences - `` Case Study – Pseudocyst Of Pancreas”.
Field of Expertise
Bariatric (weight loss) and Metabolic surgery
Laparoscopic surgery for Gall stones, appendix and hernias -Abdominal wall reconstruction for complex Hernias
Advanced Laparoscopic surgeries
GI and colorectal surgeries
Laser surgery for piles, fissures, fistula and pilonidal sinus
Breast (benign and cancer) surgery
Laparoscopic gynaecology surgeries
Fellowship & Membership
Royal College of Surgeons of England.
American College of Surgeons.
International Federation for Surgery of Obesity and Metabolic disorders.
Obesity Surgery Society of India.
Association of Surgeons of India.
Indian Association of Gastrointestinal Endosurgeons.
Association of Minimal Access Surgeons of India.
Languages Spoken
English
Hindi
Marathi
Awards & Achievements
Organising member of the Robosurge Conference 2015 at Sir Gangaram Hospital, New Delhi.
Organising member of the VTECon 2013 at Leela Kempinski, Gurgaon.
Delegate at 33rd Annual Conference Of MASICON February 2011, Mumbai.
Training programme on Simulated Techniques In Proximate Staplers at Ethicon Institute Of Surgical Education August 2010, Mumbai.
Best Paper Presentation- Diaphragmatic Hernia” at the 189th Research Meeting of Medical Research Centre Of Bombay Hospital.
1st position in Medi-Quiz at Inter-collegiate level, 2007.
2nd position in P.S.M. Quiz at Inter-collegiate level, 2006.
Talks & Publications
Bhardwaj AM, Trehan KK, Sharma V. Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: Our patient series over a period of 10 years. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 18].
Case report – Tuberculous splenic abscess” Bombay Hospital Index-Journal- Volume 54, No. 1, January 2012.
Dissertation to the Maharashtra University Of Health Sciences - `` Case Study – Pseudocyst Of Pancreas”.
Awards & Achievements
Organising member of the Robosurge Conference 2015 at Sir Gangaram Hospital, New Delhi.
Organising member of the VTECon 2013 at Leela Kempinski, Gurgaon.
Delegate at 33rd Annual Conference Of MASICON February 2011, Mumbai.
Training programme on Simulated Techniques In Proximate Staplers at Ethicon Institute Of Surgical Education August 2010, Mumbai.
Best Paper Presentation- Diaphragmatic Hernia” at the 189th Research Meeting of Medical Research Centre Of Bombay Hospital.
1st position in Medi-Quiz at Inter-collegiate level, 2007.
2nd position in P.S.M. Quiz at Inter-collegiate level, 2006.
Fellowship & Membership
Royal College of Surgeons of England.
American College of Surgeons.
International Federation for Surgery of Obesity and Metabolic disorders.
Obesity Surgery Society of India.
Association of Surgeons of India.
Indian Association of Gastrointestinal Endosurgeons.
Association of Minimal Access Surgeons of India.
Field of Expertise
Bariatric (weight loss) and Metabolic surgery
Laparoscopic surgery for Gall stones, appendix and hernias -Abdominal wall reconstruction for complex Hernias
Advanced Laparoscopic surgeries
GI and colorectal surgeries
Laser surgery for piles, fissures, fistula and pilonidal sinus
Breast (benign and cancer) surgery
Laparoscopic gynaecology surgeries
Languages Spoken
English
Hindi
Marathi
Talks & Publications
Bhardwaj AM, Trehan KK, Sharma V. Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: Our patient series over a period of 10 years. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 18].
Case report – Tuberculous splenic abscess” Bombay Hospital Index-Journal- Volume 54, No. 1, January 2012.
Dissertation to the Maharashtra University Of Health Sciences - `` Case Study – Pseudocyst Of Pancreas”.
Talks & Publications
Bhardwaj AM, Trehan KK, Sharma V. Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: Our patient series over a period of 10 years. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 18].
Case report – Tuberculous splenic abscess” Bombay Hospital Index-Journal- Volume 54, No. 1, January 2012.
Dissertation to the Maharashtra University Of Health Sciences - `` Case Study – Pseudocyst Of Pancreas”.
Fellowship & Membership
Royal College of Surgeons of England.
American College of Surgeons.
International Federation for Surgery of Obesity and Metabolic disorders.
Obesity Surgery Society of India.
Association of Surgeons of India.
Indian Association of Gastrointestinal Endosurgeons.
Association of Minimal Access Surgeons of India.
Field of Expertise
Bariatric (weight loss) and Metabolic surgery
Laparoscopic surgery for Gall stones, appendix and hernias -Abdominal wall reconstruction for complex Hernias
Advanced Laparoscopic surgeries
GI and colorectal surgeries
Laser surgery for piles, fissures, fistula and pilonidal sinus
Breast (benign and cancer) surgery
Laparoscopic gynaecology surgeries
Languages Spoken
English
Hindi
Marathi
Awards & Achievements
Organising member of the Robosurge Conference 2015 at Sir Gangaram Hospital, New Delhi.
Organising member of the VTECon 2013 at Leela Kempinski, Gurgaon.
Delegate at 33rd Annual Conference Of MASICON February 2011, Mumbai.
Training programme on Simulated Techniques In Proximate Staplers at Ethicon Institute Of Surgical Education August 2010, Mumbai.
Best Paper Presentation- Diaphragmatic Hernia” at the 189th Research Meeting of Medical Research Centre Of Bombay Hospital.
1st position in Medi-Quiz at Inter-collegiate level, 2007.
2nd position in P.S.M. Quiz at Inter-collegiate level, 2006.
Rescheduling of doctor appointment can be done within a week from the date of appointment as per doctor / slot availability.
Cancellation can be done with full refund of the payment.
2) Up to 2 hrs of appointment time:
Rescheduling of doctor appointment can be done within a week from the date of appointment as per doctor / slot availability.
Cancellation of appointment and refund with a cancellation charge of Rs.100/-.
3) Less than 2 hrs of appointment time:
Rescheduling / cancellation of appointment cannot be done, payment non-refundable in this case. However, Units can have the discretion to refund / reschedule in case of exigencies.
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PATIENT CONSENT FOR TELEMEDICINE / TELECONSULTATION
Telemedicine involves the use of electronic communications to enable Hospitals/health care centres to provide healthcare services at different locations through exchange of information and for the purpose of improving patient care. I, confirm that I have received the necessary information to sign this form and I agree to take part in a live telemedicine/teleconsultation session with Manipal Hospitals.
I understand that:
Interactive audio/video connection, electronic information and communication technologies shall be used for providing me with a telemedicine/teleconsultation.
In case the information obtained via teleconsultation is not sufficient to make a diagnosis, I may be required to go to Manipal Hospitals for in-person consultation.
Though the telemedicine/teleconsultation is private, other individuals, medical and non-medical, may be present to facilitate the consultation and that they will take reasonable steps to maintain confidentiality of the information obtained.
A limited visual examination will take place during the telemedicine/teleconsultation and that it cannot replace a full medical examination done physically at Manipal Hospitals.
I have the right to withhold or withdraw my consent to the use of telemedicine/teleconsultation in the course of my care at any time, without affecting my right to future care or treatment. I may also revoke my consent orally or in writing at any time.
I may be prescribed medicines for treatment or/and diagnostic tests to further evaluate my health condition. All prescription will be sent to my registered email/phone no. Manipal Hospitals will keep a record of the consultation & prescription in my medical record.
The telemedicine/teleconsultation services are not in any way intended to be used in case of an emergency.
There can be potential risks with this technology e.g information transmitted may not be sufficient to allow for appropriate medical decision, the video /audio may disconnect/stop in-between, security protocols could fail causing a breach of privacy of personal medical information.
Any relevant medical information about me including details of my medical history, examinations, x-rays, tests, photographs or other images may be transmitted /shared by Manipal Hospitals with their staff, specialist, business partners for the purpose of record, communications, feedback, enquires, follow ups, analysis etc.
Manipal Hospitals responsibility shall terminate upon conclusion of this teleconference.
I hereby consent that in consideration for the telemedicine / teleconsultation services rendered to me, I agree to pay the relevant charges.
I hereby release Manipal Hospitals, its personnel and any other person participating in my care from any and all liability which may arise from authorized use of such Video / E-Consultation, Videotapes, Digital recording films and Photographs. I have read this document and understand the risk of the telemedicine / teleconsultation.
I hereby consent to participate in a telemedicine / teleconsultation under the terms & conditions described in this document.