Consent and Release of Personal Information

Global HealthQuest collects personal information to assist it in delivering services such as medical tourism programs, rehabilitation and international travel. We acknowledge that information acquired as a result of providing these services is protected by privacy laws. We take our responsibilities under these statutes seriously and have established safeguards to protect personal information in our possession. However, in order to deliver our services, it is sometimes necessary for us to share personal information with other professionals involved in the development of the medical tourism program, rehabilitation and/or international travel. As a result, we must ask each client to authorize Global HealthQuest to collect and share personal information as necessary to deliver our services effectively.

In order to deliver services of a medical tourism, rehabilitation and international travel nature, I, hereby authorize Global HealthQuest to collect relevant personal information about me. I acknowledge that Global HealthQuest may receive and review copies of medical and other related records from professionals involved in my program in order to deliver its services to me, and that employees of Global HealthQuest may discuss pertinent information with those professionals. Furthermore, I authorize Global HealthQuest to release to professionals involved in my program any information pertaining to these services that it has collected, including medical results and progress reports. Global HealthQuest may not release personal information to any other party without my consent unless permitted or required to do so by law.

Global HealthQuest Inc. supports the right of access to medical care and has screened medical facilities around the world for exceptional treatment. In consideration of participating in this treatment program, I myself, my heirs, executors, administrators, successors and assigns, do hereby release and forever discharge, waive and save harmless, protect and keep indemnified Global HealthQuest Inc., and all of its respective agents, employees, and representatives from and against any and all kinds of actions, claims, costs, expenses and demands in respect of death, injury, loss or damage of any kind whatsoever to my person or property however caused arising out of my being permitted to attend at or in any way take part in this treatment program as a participant.

This consent to the collection and release of personal information expires seven (7) years from the date signed. However, it may be revoked at any time by presenting Global HealthQuest with written notification. This notification may be mailed to: Privacy Officer, Global HealthQuest, 55 City Centre Drive, Suite 400, Mississauga, ON L5B 1M3

All of the above information has been explained to me to my satisfaction.

In an effort to monitor ongoing quality with respect to service delivery, from time to time, we request that clients provide testimonial to the services received from Global HealthQuest Inc. In addition, Global HealthQuest may use this information for marketing purposes. Please review the below options and provide consent where agreed by endorsing ‘Yes’ or ‘No’ with your initials: