Informed Consent

Patient Information

Name: ___________________________________
Age: ___________________________________
Address: ___________________________________
Contact Information: ________________________
Emergency Contact: ________________________

Treatment Description

I, the patient, acknowledge that I have been informed about and understand the medical procedure(s) to be performed, which include:
[Radiotherapy / Urology / Oncology treatment / Other]

The risks, benefits, and alternative treatment options have been clearly explained to me in detail by my healthcare provider.

I understand that all medical services will be provided in Mexico. HealthBridge MX’s role is to coordinate my medical treatment, accommodations, transportation, and related services, but HealthBridge MX is not responsible for medical outcomes or clinical decisions.

Risks and Acknowledgments

I acknowledge that the proposed medical treatment(s) carry inherent risks, including but not limited to side effects, complications, or possible failure of the procedure. These risks have been thoroughly explained to me by the medical team.

I agree to adhere to all post-treatment care instructions, attend scheduled follow-up appointments, and report any complications or concerns promptly to both HealthBridge MX and my treating healthcare provider.

Consent for Treatment

I, [Patient Name], voluntarily consent to the proposed medical treatment(s). I have been informed about and understand the associated risks and benefits, and I authorize the treatment to proceed.

I acknowledge that HealthBridge MX will coordinate my medical care, travel arrangements, and accommodations but is not liable for any medical complications or outcomes that may arise.

I agree to the payment terms outlined by HealthBridge MX and understand that full payment is required before any treatment is administered.

I consent to the sharing of my medical information with healthcare providers involved in my treatment to ensure proper coordination and continuity of care.

Customization by Service Package

Basic Package:

  • Medical appointment and treatment coordination
  • Document translation
  • Hospital coordination
  • Consent for treatment and understanding of travel arrangements (patient confirms understanding of treatment risks and travel details)

Medium Package:
Includes all Basic Package services, plus:

  • Flight booking and accommodation arrangements
  • Consent covering medical treatment, travel, and lodging coordination

Premium Package:
Includes all Medium Package services, plus:

  • Ground transportation (airport, hotel, clinic)
  • 24/7 bilingual support during treatment period
  • Special consent for transportation and continuous support services (patient confirms understanding of additional services)

Additional Acknowledgments

  • I understand that HealthBridge MX acts solely as an intermediary between myself and the healthcare providers.
  • While HealthBridge MX coordinates logistics and service quality, it does not assume responsibility for medical decisions or treatments performed by licensed physicians in Mexico.
  • I authorize HealthBridge MX to share necessary personal and medical information with healthcare providers for the purpose of coordinating my care.
  • I understand that I may modify or withdraw my consent at any time prior to treatment, recognizing this may affect scheduling and logistical arrangements.

Patient Signature

I, [Patient Name], confirm that I have read, understood, and voluntarily agree to the conditions outlined above. I acknowledge the risks, benefits, and alternatives associated with my proposed medical treatment, and I give my informed consent to proceed.

Signature: _________________________
Date: _____________________________

Healthcare Provider Confirmation

I confirm that I have explained the nature, risks, benefits, and alternatives of the proposed treatment to the patient, and that the patient has provided informed consent.

Signature: _________________________
Date: _____________________________

Important Notes

  • Right to Withdraw Consent: The patient may withdraw consent at any time before treatment begins.
  • Follow-up Care: Patients will receive clear post-treatment instructions and follow-up plans, especially regarding any potential complications.
  • Additional Risks: Should any new risks or changes arise after consent is given, updated consent will be required before proceeding.