The Medical Declaration Form is a crucial document required by healthcare facilities operating in the United Arab Emirates, designed to comply with UAE Federal Law No. 4 of 2016 and related healthcare regulations. This document is mandatory for patient registration and treatment in UAE healthcare facilities, serving multiple purposes including risk management, legal compliance, and patient care optimization. It captures essential information about the patient's health status, medical history, and provides necessary consents for treatment while protecting both the healthcare provider and patient's interests. The form must be completed prior to receiving medical treatment and is particularly important in establishing the baseline health status of patients, documenting informed consent, and ensuring compliance with UAE healthcare documentation requirements.
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1. Personal Information: Patient's full legal name, Emirates ID, date of birth, gender, and contact details
2. Emergency Contact Information: Details of primary and secondary emergency contacts
3. Current Medical Status: Present health conditions, medications, and allergies
4. Medical History: Past medical conditions, surgeries, and significant health events
5. Family Medical History: Relevant family medical conditions and genetic predispositions
6. Declaration of Truth: Patient's confirmation that all provided information is accurate and complete
7. Consent for Treatment: General consent for medical examination and treatment
8. Information Sharing Authorization: Consent for sharing medical information with healthcare providers
9. Financial Responsibility: Acknowledgment of financial obligations and insurance information
10. Signature Section: Space for patient/guardian signature, date, and witness confirmation
1. Pregnancy Declaration: For female patients of childbearing age, declaration of known/suspected pregnancy status
2. Mental Health Status: For facilities providing mental health services, additional mental health history and current status
3. Infectious Disease Declaration: For use during epidemics or in specialized clinics, declaration of exposure to specific infectious diseases
4. Travel History: For international patients or during public health emergencies, recent travel history declaration
5. Guardian Information: For minors or patients requiring guardianship, legal guardian details and authority
6. Language Assistance: For non-Arabic/non-English speaking patients, preferred language and interpreter requirements
7. Research Participation: Optional consent for participation in medical research or clinical trials
1. Schedule A - Detailed Medical History Form: Comprehensive checklist of medical conditions and history
2. Schedule B - Medication List: Detailed current medication schedule including dosage and frequency
3. Schedule C - Privacy Policy: Detailed explanation of how medical information will be used and protected
4. Schedule D - Patient Rights and Responsibilities: Comprehensive list of patient rights and responsibilities under UAE law
5. Appendix 1 - Insurance Information: Detailed insurance policy information and coverage details
6. Appendix 2 - Facility-Specific Policies: Relevant healthcare facility policies and procedures
7. Appendix 3 - Consent Forms: Specific consent forms for various medical procedures
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