DMT Club - Eligibility Application Form

ELIGIBLITY APPLICATION FORM 1 | P a g e MEDICAL TOURISM CLUB ELIGIBILITY APPLICATION FORM Thank you for your interest in being a part of the Medical Tourism Club, in Dubai. Please complete all sections (11 pages in total) below in BLOCK CAPITALS and return the completed application form to: Pradeep V Thampi, Health Regulation Department, Dubai Health Authority, Block “B”, Business Village, Diera – Dubai. If you have any questions concerning this form or the Medical Tourism Club Membership in general, please get in touch with our team by telephone on +971 4 5022941 or by email t o m e d i c a l t o u r i s m @ d h a . g o v . a e MEMBERSHIP All healthcare facilities that actively promote, facilitate and participate in medical tourism in Dubai are eligible to apply to become a member of the Medical Tourism Club. The members of the club shall be categorized based on the survey conducted by the DHA, Health Regulation Department. 
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Platinum ( >80 % score) Gold ( 60‐80 % score) Silver ( <60% score) MEMBERSHIP BENEFITS 
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Networking opportunities. Opportunity to present their ideas to other members at events. Collaborate on research opportunities. Ability to post on the Club website members’ section. BENEFITS BY MEMBERSHIP TYPE Platinum Members 
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Facility Logo, with hyperlink to the facility website, to be specially listed on DMT website, for 12 months. Preferential listing & positioning of facility on DMT website. (Listing in alphabetical order, if more than one facility) Privilege to participate in all regional & international Medical Tourism events with DHA (Excludes Relevant Fee & Other Expenses) Inclusion of Health facility logo in all DHA medical tourism collaterals like leaflets, brochures, newsletters etc. Preferential location of exhibition stands in Medical Tourism events conducted by DHA Preferential participation in training and certification programs, on Medical Tourism organized by DHA (Excludes Relevant Fee & Other Expenses) Use of Dubai medical tourism logo (With prior written approval from DHA) Gold Members 
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Facility Logo, to be listed on DMT website, for 12 months. (Smaller size compared to Platinum) Privilege to participate in Medical Tourism events. (Excludes Relevant Fee & Other Expenses) Preferential participation in training & certification programs on Medical Tourism. (Excludes Relevant Fee & Other Expenses) Permission to use DMT logo, on Facilities marketing material. (With prior written approval from DHA) Silver Members 
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Facility to be listed in Dubai Medical Tourism (DMT) website. Participation in Medical Tourism events, by invitation (Excludes Relevant Fee & Other Expenses) Preferential participation in training & certification programs on Medical Tourism. (Excludes Relevant Fee & Other Expenses) Permission to use DMT logo, on Facilities marketing material. (With prior written approval from DHA) QUALIFYING CRITERIA Each membership application will be examined as to whether it meets the minimum criteria for Membership and a particular type of Membership. Whether a Member meets the requisite criteria for its membership type shall be reviewed annually. DHA shall have absolute discretion in its decision whether to accept a specific Member or the type of Membership assigned. 2 | P a g e MEDICAL TOURISM CLUB ELIGIBILITY APPLICATION FORM FACILITY NAME APPLICANT DETAILS – CONTACT INFORMATION
ADDRESS TELEPHONE +971 WEBSITE Email 1. 2. Email: Email: CONTACT PERSON/s MEDICAL DIRECTOR Email: NOTE: The Contact person/s will be the single point of contact between the Member and the DHA. The contact will receive all publications, notifications and event invites. Each Member MUST nominate a maximum of 2 contact persons and Membership will not be granted without valid coordinator’s details.
FACILITY INFORMATION
DATE OF COMMENCING OPERATIONS FACILITY TYPE SPECIALITIES AVAILABLE (DD) / (MM)/ (YYYY) Hospital Day Surgical Centre Outpatient Diagnostic imaging Centre Clinical laboratories Orthopedics and Sports Medicine Plastic surgery Dental Procedures Preventive Health check‐ups Dermatology Ophthalmology Wellness & Spa Please list other specialties, if available. 1.
BRANCHES, IF ANY
NUMBER OF DOCTORS
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3. 4.` 5. 6. Hospitals
(number)
Clinics
(number)
Others
(number)
Fulltime
(number)
Total Number of beds
Part time
(number)
(number)
MEDICAL TOURISM CLUB ELIGIBILITY APPLICATION FORM FACILITY INFORMATION
ACCREDITATION
Yes
No
Details
Valid until
(DD) / (MM)/ (YYYY) INTERNATIONAL
AFFILIATION
1. List of branches in other cities / countries
2. Affiliation with other clinic/ hospital abroad
3. JV or Investment in Hospitals or Clinics outside UAE
OWNERSHIP / MANAGEMENT
Facility managed / owned by an established facility from another country?
Yes
No
If yes, please provide details
Parent Organisation & Head Office Address
IMPORTANT
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Please fill in the survey form (Attached at the end of the application form) and send it to Health
Regulations Department, for DHA evaluation.
4 | P a g e MEDICAL TOURISM CLUB ELIGIBILITY APPLICATION FORM MEDICAL TOURISM
IS YOUR FACILITY CURRENTLY PROMOTING MEDICAL TOURISM
Yes
If Yes, List Activities
No
Website
Facilitators
Events
Promotions Abroad
Others
HOSPITALITY SERVICES OFFERED Patient Coordinator
Translator
Hotel Stay Discounts
Airport Pick Up & Drop Off
Others
Are you willing to lock prices for procedures, for a period of one year, to participate in the Medical Tourism
Program, promoted by the Government of Dubai?
Yes
No
Yes
No
If yes, are they promotional prices?
List five specialties that your facility believes is a business opportunity for Medical Tourism.
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3. 4. 5. NUMBER OF MEDICAL TOURISTS IN 2012 & 2013
numbers 2012
numbers 2013
TOP 3 COUNTRIES THAT MEDICAL TOURISTS CAME FROM
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3. CURRENTLY DO YOU REGISTER & ACCOUNT FOR MEDICAL TOURIST SEPARATELY? Yes
No
5 | P a g e MEDICAL TOURISM CLUB ELIGIBILITY APPLICATION FORM DECLARATION
DHA may accept or reject applications for Club Membership. Its decisions are final. The signed Contract constitutes a legally binding agreement. The outcome of all applications is confirmed in writing. 
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By signing this Application Form, I confirm I have read and agree with the Terms and Conditions of Membership. I warrant that I have the authority to apply on behalf of and to bind the organization applying, for membership. Signature Date Name Organisation Agree to the Company’s logo and name being displayed in the Dubai Medical Tourism website & promotional material. Company Stamp 6 | P a g e MEDICAL TOURISM CLUB ELIGIBILITY APPLICATION FORM 1.
TERMS & CONDITIONS
DEFINITIONS In these Terms and Conditions: 
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“Applicant” means the person, firm, company or Organisation identified as such on the Membership Application Form. “Club” means the not for profit grouping of professionals in the health care industry, which has no legal establishment or personality, administered by DHA and known as the Dubai Medical Tourism Club. “Club Administration” means the DHA appointed executives responsible for the administration of the Club. “DHA” means Dubai Health Authority. “Member” means the person, firm, company or organisation who is licensed by DHA. “Eligibility Application Form” means the application form for admission to the Club, as prescribed by the Club Administration from time to time. “Membership Type” means the levels of membership granted to a Member, depending on its ability to meet the relevant criteria laid out by DHA. 2.
LANGUAGE 
The proceedings of the Club and its documentation shall be in the English language. Submission by Members to the Club shall be in English and any translation of the Club documentation shall be the responsibility of the Member requiring it. 3.
MEMBERSHIP Benefits 
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Details of benefits of Membership attributed to each Membership Type will be outlined on the Club’s official website (once launched) or can be requested from the Club Club Administration reserves the right to change Membership Types and benefits from time to time but shall give Members 10 days’ notice displayed on the Club’s website prior to implementing such changes. Application Process IN ORDER TO BE ADMITTED AS A MEMBER, AN APPLICANT MUST 
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Provide a completed Membership Application Form Supply all relevant information contained on the Membership Application Form and/or requested by the Club Administration to establish the Applicant’s eligibility and the type of membership. Nominate a coordinator to be the main point of contact between the Club and the Member and who will have necessary authority to make decisions on behalf of the Member. Receive notification from DHA or the Club Administration that the Applicant’s Membership Application Form has been accepted and specifying the Membership Type granted to the Applicant. Determination of membership 
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Acceptance of an Applicant into the Club and Membership Type granted, is in the DHA’s and the Club Administration’s absolute discretion. Members must notify the Club Administration in writing any changes that may affect its eligibility for membership or its Membership Type. Members must confirm, upon renewal of membership, that they meet the relevant criteria for Membership Type and will be allowed to change their Membership Type, if they so wish. The Club Administration may review its Members’ status from time to time. MEMBERSHIP FEES 
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Notwithstanding the conditions listed below the Membership to Dubai Medical Tourism Club is FREE, until any further notice from DHA or the Club Administration. The membership year begins on January 1 and ends on 31 December of each calendar year, subscriptions are payable annually in advance. The Club will issue an invoice in the amount applicable to the relevant Membership Type, prior to an Applicant being eligible for membership. Membership fees may be revised and will be notified to Members on the Club’s website. Payments, if any, must be made within 30 calendar days from the date of the invoice and must be in UAE Dirhams only. All invoices will be sent to the address designated in the Membership Application Form. No refund. Fees for Members joining mid‐year will be calculated pro rata rounded down to the nearest month. 7 | P a g e MEDICAL TOURISM CLUB ELIGIBILITY APPLICATION FORM 5.
TERMS & CONDITIONS
INTELLECTUAL PROPERTY 
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Each Member consents to the Club using the Member’s name, logo and trademark on the Club’s website, in its official publications or other materials, if the Member has consented to its use in the Application Form. Each Member agrees and consents to its name being published in the Members’ directory. Each Member acknowledges and agrees that the Club is entitled to keep a list of Members’ names, addresses and other contact details. 6.
LIABILITY 
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DHA or the Club Administration shall not be under any duty or obligation to, nor shall it assume any liability to, any Member or delegate of any Member in respect of the Club, any publication, or any meeting, event or other activity of the Club. Each Member warrants, represents and undertakes to the Club and the DHA that it and its delegates who participate in any way in any event organised by the Club, do so at their own cost and risk, and waive any and all rights they may otherwise have against the DHA / Dubai Medical Tourism Club in this regard. Without prejudice to the generality of the foregoing, the terms on which the Club provides any benefits for any Membership Type, excludes and/or limits all forms of liability of the DHA / Dubai Medical Tourism to the fullest extent allowable under law. 7.
TERMINATION A Member shall immediately cease to be a Member if one of the following events occur. 
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if a Member resigns by not less than 3 months with a written notice addressed to the Club Administration. if the DHA or the Club Administration determine that a Member is no longer eligible for membership. if an invoice issued by the Club remain unpaid for 30 days after becoming due. 8.
VARIATION 
Terms and Conditions of membership may be revised by DMCC from time to time and will be notified to Members in writing by the Club Administration and or be published on the Club’s website (once launched). 9.
PARTNERSHIP 
Membership of the Club shall not imply any partnership, duty, obligation or right of any Member or the DHA / Dubai Medical Tourism Club save as expressly set out herein. FACILITY SURVEY
1) A brief description of specialties, prices, key specialists/ surgeons, volumes and international accreditation and/ or internationally reputed certification your facilities have received. (please fill a separate form for each hospital / clinic / medical centre under your management in Dubai) Specialty Ophthalmology Cosmetic Surgeries 8 | P a g e Procedure/ treatment
Vision correction by implantation of lenses Corneal graft LASIK Surgical treatment of glaucoma Surgical treatment of strabismus Rhinoplasty Face lift Breast Augmentation Eyelids and Forehead Volumes (2013)
Current Prices (in AED) Key Specialists/ Surgeons (Name as per Sheryan license) Dental Procedures Orthopedic Surgeries and Sports Medicine Wellness and Dermatology surgery Hair Transplantation Tummy tuck Breast Reduction Crowns Dentures Veneers Implants Root canal Tooth Whitening Knee replacements Hip replacements Spinal surgeries Sports Medicine Health check ups Spas – Detox & Rejuvenation packages Weight loss Treatments
Health Nutrition Laser Hair Removal Skin treatments Fertility treatment IVF Genetics Intracytoplasmic sperm injections (ICSI) Laparoscopic surgery Gender Determination tests 2) A one page CV for each of the above surgeons / specialists listing their educational qualifications, credentials and their experience with a possible mention of number of procedures performed related to their clinical specialties Please attach a pdf of CVs 3) A brief on visiting clinicians to your facility with a two line description of their qualifications and experience (Related to procedures and treatments within the medical tourism priorities only as listed in #2 above) Name of the Facility visited 9 | P a g e Procedure / Treatment Name of the visiting clinician
Credentials / Experience in 1 line 4) Clinical outcomes at your facilities for the above listed procedures/ treatments (Optional, but highly recommended). Facility Facility 1 Facility 2 Facility 3 Clinical Indicator (KPI)
Eg. ‐ In hospital mortality
Eg. ‐ Infection rates Eg. ‐ Hospital readmission rate
Etc. Clinical Outcome in 2012 (annual) PROMOTIONAL PRICES FOR MEDICAL TOURISM PACKAGES
Please tick (√) against the service that your facility is keen to promote, and fill in the below table. If you want to participate with more services, please list (Up to 5) in the table below. Services Current Promotional Package inclusions e.g. number of Prices prices sessions/ consultations, hospital (AED) (AED) stay, tests and diagnostics, etc. 1. Ophthalmology Vision correction by implantation of lenses Corneal graft LASIK Surgical treatment of glaucoma Surgical treatment of strabismus 2. Cosmetic Surgeries Rhinoplasty Face lift Breast Augmentation Eyelids and Forehead surgery Hair Transplantation Tummy tuck 3. Dental Procedures Crowns Dentures Veneers Implants Root canal Tooth Whitening 4.
Orthopedic Surgeries and Sports Medicine
Knee replacements Hip replacements Spinal surgeries 10 | P a g eSports Medicine Services Current Prices (AED) Promotional prices (AED) Package inclusions e.g. number of sessions/ consultations, hospital stay, tests and diagnostics, etc 5. Ophthalmology Vision correction by implantation of lenses Corneal graft LASIK Surgical treatment of glaucoma Surgical treatment of strabismus 6. Cosmetic Surgeries Rhinoplasty Face lift Breast Augmentation Eyelids and Forehead surgery Hair Transplantation Tummy tuck 7. Dental Procedures Crowns Dentures Veneers Implants Root canal Tooth Whitening 8. Orthopedic Surgeries and Sports Medicine
Knee replacements Hip replacements Spinal surgeries Sports Medicine END OF APPLICATION FORM & FACILITY SURVEY
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