E-Consent

Country CodeAFGHANISTAN ( +93 )ALBANIA ( +355 )ALGERIA ( +213 )AMERICAN SAMOA ( +1684 )ANDORRA ( +376 )ANGOLA ( +244 )ANGUILLA ( +1264 )ANTARCTICA ( +672 )ANTIGUA AND BARBUDA ( +1268 )ARGENTINA ( +54 )ARMENIA ( +374 )ARUBA ( +297 )ASCENION ( +247 )AUSTRALIA ( +61 )AUSTRIA ( +43 )AZERBAIJAN ( +994 )BAHAMAS ( +1242 )BAHRAIN ( +973 )BANGLADESH ( +880 )BARBADOS ( +1246 )BELARUS ( +375 )BELGIUM ( +32 )BELIZE ( +501 )BENIN ( +229 )BERMUDA ( +1441 )BHUTAN ( +975 )BOLIVIA ( +591 )BONIRE, SINT EUSTATIUS AND SABA ( +599 )BOSNIA AND HERZEGOVINA ( +387 )BOTSWANA ( +267 )BRAZIL ( +55 )BRITISH INDIAN OCEAN TERRITORY ( +246 )BRITISH VIRGIN ISLANDS ( +1-284 )BRUNEI ( + 673 )BRUNEI DARUSSALAM ( +673 )BULGARIA ( +359 )BURKINA FASO ( +226 )BURUNDI ( +257 )CABO VERDE ( +238 )CAMBODIA ( +855 )CAMEROON ( +237 )CANADA ( +1 )CAPE VERDE ( +238 )CAYMAN ISLANDS ( +1345 )CENTRAL AFRICAN REPUBLIC ( +236 )CHAD ( +235 )CHILE ( +56 )CHINA ( +86 )CHRISTMAS ISLAND ( +61 )COCOS (KEELING) ISLANDS ( +61 )COLOMBIA ( +57 )COMOROS ( +269 )CONGO ( +242 )CONGO, THE DEMOCRATIC REPUBLIC OF THE ( +243 )COOK ISLANDS ( +682 )COSTA RICA ( +506 )COTE D IVOIRE ( +225 )CROATIA ( +385 )CUBA ( +53 )CURACAO ( +599)CYPRUS ( +357 )CZECH REPUBLIC ( +420 )DEMOCRATIC REPUBLIC OF THE CONGO ( +243 )DENMARK ( +45 )DJIBOUTI ( +253 )DOMINICA ( +1767 )DOMINICAN REPUBLIC ( +1809, +1829, +1849 )EAST TIMOR ( +670 )ECUADOR ( +593 )EGYPT ( +20 )EL SALVADOR ( +503 )EQUATORIAL GUINEA ( +240 )ERITREA ( +291 )ESTONIA ( +372 )ESWANTINI ( +268 )ETHIOPIA ( +251 )FALKLAND ISLANDS (MALVINAS)( +500 )FAROE ISLANDS ( +298 )FIJI ( +679 )FINLAND ( +358 )FRANCE ( +33 )FRENCH GUIANA ( +594)FRENCH POLYNESIA ( +689 )GABON ( +241 )GAMBIA ( +220 )GAZA STRIP ( +970 )GEORGIA ( +995 )GERMANY ( +49 )GHANA ( +233 )GIBRALTAR ( +350 )GREECE ( +30 )GREENLAND ( +299 )GRENADA ( +1473 )GUADELOUPE ( +590 )GUAM ( +1671 )GUATEMALA ( +502 )GUERNSEY ( +441481 )GUINEA ( +224 )GUINEA-BISSAU ( +245 )GUYANA ( +592 )HAITI ( +509 )HOLY SEE (VATICAN CITY STATE)( +39 )HONDURAS ( +504 )HONG KONG ( +852 )HUNGARY ( +36 )ICELAND ( +354 )INDIA ( +91 )INDONESIA ( +62 )IRAN, ISLAMIC REPUBLIC OF ( +98 )IRAQ ( +964 )IRELAND ( +353 )ISLE OF MAN ( +44 )ISRAEL ( +972 )ITALY ( +39 )IVORY COAST ( +225 )JAMAICA ( 1876 )JAPAN ( +81 )JERSY ( +4-1534 )JORDAN ( +962 )KAZAKSTAN ( +7 )KENYA ( +254 )KYRGYZSTAN ( +996 )KIRIBATI ( +686 )KOREA DEMOCRATIC PEOPLES REPUBLIC OF ( +850 )KOREA REPUBLIC OF ( +82 )KOSOVO ( +381 )KUWAIT ( +965 )LAO PEOPLES DEMOCRATIC REPUBLIC ( +856 )LATVIA ( +371 )LEBANON ( +961 )LESOTHO ( +266 )LIBERIA ( +231 )LIBYA ( +218 )LIBYAN ARAB JAMAHIRIYA ( +218 )LIECHTENSTEIN ( +423 )LITHUANIA ( +370 )LUXEMBOURG ( +352 )MACAU ( +853 )MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF ( +389 )MADAGASCAR ( +261 )MALAWI ( +265 )MALAYSIA ( +60 )MALDIVES ( +960 )MALI ( +223 )MALTA ( +356 )MARSHALL ISLANDS ( +692 )MAURITANIA ( +222 )MAURITIUS ( +230 )MAYOTTE ( +262 )MEXICO ( +52 )MICRONESIA, FEDERATED STATES OF ( +691 )MOLDOVA, REPUBLIC OF ( +373 )MONACO ( +377 )MONGOLIA ( +976 )MONTENEGRO ( +382 )MONTSERRAT ( +1664 )MOROCCO ( +212 )MOZAMBIQUE ( +258 )MYANMAR ( +95 )NAMIBIA ( +264 )NAURU ( +674 )NEPAL ( +977 )NETHERLANDS ( +31 )NETHERLANDS ANTILLES ( +599 )NEW CALEDONIA ( +687 )NEW ZEALAND ( +64 )NICARAGUA ( +505 )NIGER ( +227 )NIGERIA ( +234 )NIUE ( +683 )NORTH KOREA ( +850 )NORTHERN MARIANA ISLANDS ( +1670 )NORWAY ( +47 )OMAN ( +968 )PAKISTAN ( +92 )PALAU ( +680 )PALESTINE( +970 )PANAMA ( +507 )PAPUA NEW GUINEA ( +675 )PARAGUAY ( +595 )PERU ( +51 )PHILIPPINES ( +63 )PITCAIRN ( +870 )POLAND ( +48 )PORTUGAL ( +351 )PUERTO RICO ( +1 )QATAR ( +974 )REPIBLIC OF THE CONGO ( +242 )REUNION ( +262 )ROMANIA ( +40 )RUSSIAN FEDERATION ( +7 )RWANDA ( +250 )SAINT BARTHELEMY ( +590 )SAINT HELENA ( +290 )SAINT KITTS AND NEVIS ( +1869 )SAINT LUCIA ( +1758 )SAINT MARTIN ( +1599 )SAINT PIERRE AND MIQUELON ( +508 )SAINT VINCENT AND THE GRENADINES ( +1784 )SAMOA ( +685 )SAN MARINO ( +378 )SAO TOME AND PRINCIPE ( +239 )SAUDI ARABIA ( +966 )SENEGAL ( +221 )SERBIA ( +381 )SEYCHELLES ( +248 )SIERRA LEONE ( +232 )SINGAPORE ( +65 )SINT MAARTEN( +1721 )SLOVAKIA ( +421 )SLOVENIA ( +386 )SOLOMON ISLANDS ( +677 )SOMALIA ( +252 )SOUTH AFRICA ( +27 )SOUTH KOREA ( +82 )SOUTH SUDAN ( +211 )SPAIN ( +34 )SRI LANKA ( +94 )SUDAN ( +249 )SURINAME ( +597 )SALBARD AND JAN MAYEN( + 47 )SWAZILAND ( +268 )SWEDEN ( +46 )SWITZERLAND ( +41 )SYRIAN ARAB REPUBLIC ( +963 )TAIWAN, PROVINCE OF CHINA ( +886 )TAJIKISTAN ( +992 )TANZANIA, UNITED REPUBLIC OF ( +255 )THAILAND ( +66 )TIMOR-LESTE ( +670 )TOGO ( +228 )TOKELAU ( +690 )TONGA ( +676 )TRINIDAD AND TOBAGO ( +1868 )TUNISIA ( +216 )TURKEY ( +90 )TURKMENISTAN ( +993 )TURKS AND CAICOS ISLANDS ( +1649 )TUVALU ( +688 )U.S. VIRGIN ISLANDS ( +1340 )UGANDA ( +256 )UKRAINE ( +380 )UNITED ARAB EMIRATES ( +971 )UNITED KINGDOM ( +44 )UNITED STATES ( +1 )URUGUAY ( +598 )UZBEKISTAN ( +998 )VANUATU ( +678 )VATICAN ( +379 )VENEZUELA ( +58 )VIETNAM ( +84 )VIRGIN ISLANDS, BRITISH ( +1284 )VIRGIN ISLANDS, U.S. ( +1340 )WALLIS AND FUTUNA ( +681 )WESTERN SAHARA ( +212 )YEMEN ( +967 )ZAMBIA ( +260 )ZIMBABWE ( +263 )

Signature

In order to facilitate my request for home country treatment, I hereby permit and consent Bluedot Medical Assistance to get my medical reports from National Life and General Insurance Company SAOG (NLGIC insurance). And to obtain a treatment plan and secure insurance approval, I also give Bluedot Medical Assistance permission to share my medical records with the hospitals and the doctors. I am also aware that Bluedot Medical Assistance will gather my medical records following my hospitalization and submit them to the insurance in accordance with the authority's and the insurance's established procedures.