Clarion School Information Pack

School Information Pack

Page 1 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Dear Parents/Caregivers,

Neuropedia and all our staff are pleased to begin this journey with you, your
child and their schools. Thank you for requesting that we begin in-school
therapy with your child. We request that you read all the information provided
so that we can correctly familiarize ourselves with your child and provide the
best quality services. We request that you please sign all relevant documents,
and give back to your child’s teacher, or to the therapist, prior to the
assessment/start of therapy.

Information included in this “School Pack” is:

• About Neuropedia
• Services we are able to provide at your child’s school
• Registration Form
• Consent Form
• Medical release form
• Informed consent for both assessment and/or therapy
• School therapy cancellation form and discharge form
• Photo release form

Should you have any further questions, please do not hesitate to contact your
child’s prospective therapist or our reception at Neuropedia.

Name of Therapist: ___________________________________
Therapist’s email address: ___________________________________

Your therapist will discuss with both yourself and your child’s teacher the day
and time of therapy session/s and inform you of this via email. We will also
provide your child with a communication book, which will be written in after
every session. Please ensure that this book is brought to school every day that
your child has a session.

We look forward to embarking on this journey with you and your family.

Page 2 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Neuropedia

Neuropedia Children’s Neuroscience Centre is the first highly specialized
pediatric neuroscience centre in the UAE. Neuropedia provides comprehensive
care for children and young people with a wide range of disorders. The
specialist care is provided by a board-certified team of highly qualified,
motivated and passionate healthcare professionals keeping the child and family
needs central at all times. The multidisciplinary team allows for an overall
individualize evaluation, plan and treatment. We provide a service to all
children from 0-18 years.

Neuropedia works within a multi-disciplinary team framework made up of
highly trained specialist child and adult clinicians including:

• Pediatric Neurologists
• Child Psychologists
• Physiotherapists
• Speech & Language Therapists
• Occupational Therapists
• Autism / ABA Therapists
• Pediatric Dieticians
• Registered Health Nurses

We treat children with range difficulties, including the following.

• Epilepsy
• Anxiety, Mood and Depression
• Attention Deficit and Hyperactive Disorder (ADHD/ ADD)
• Autism Spectrum Disorders (ASD)
• Behavioural Disorders
• Eating Disorders
• Learning Difficulties
• Obsessive-Compulsive Disorder
• Self Harm
• Sensory Processing difficulties
• Speech and Language Difficulties
• Gross and fine motor delays
• Neuromuscular
• Movement Disorders
• Sleep disorders

Page 3 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Services

Physiotherapy (PT)

Pediatric physiotherapy aims to provide support in the gross motor
development of the children.
In everyday activities, children and adults use their muscle (power) to keep
their balance and coordinated through tasks and play. During physical
therapy, the therapist can work on improving strength and endurance to sit in
a better position at school or to keep the pace during an outing. Working on
the coordination and balance can influencing learning a new skill such as
hopping, standing on one leg or throwing a ball at a target, supporting a child
to remain on track with their motor skill development.

Examples of what our pediatric physical therapist work on:
• Endurance/ children who easily fatigue
• Development coordination disorder (DCD)
• Tone regulation problems: lower tone as well as high tone
• Gait abnormalities
• Balance training, muscle strength and coordination (including
post-injury)
• Improving skills that children struggling with during Physical
Education (PE)
• Improving posture, slouched posture is common in children, this
impacts on concentration levels.
• Neurological diagnosis; CP, epilepsy and many more

Psychology

Psychology Focusing on children and adolescence overall well-being, behaviour,
cognitive abilities and learning needs. Assessments provide comprehensive
information when identifying underlying learning difficulties and emotional
needs. Within the multi-disciplinary approach, our psychologists work closely
with teachers and learning support staff at the school, parents and other family
members, as well as other therapists who are working with your child. This will
assist your child in coping at home, school and their social environments. Our
psychologists work within the following areas:

• Cognitive assessments
• IQ testing
• Learning difficulties
• Behaviour management

Page 4 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

• Anxiety disorders and/or needs
• Self-esteem and confidence
• Dyslexia Assessment

Speech and Language Therapy

The main aim of speech and language therapy is to assist the child in
developing successful independent communication skills; from pre-linguistic
(i.e., eye contact, turn-taking, play) to social communication (both written and
verbal). By developing effective communication skills, the child is able to
participate effectively within the social world. The therapist will assess the
child’s developmental level and implement a therapy plan catered for the
individual child’s needs. The process involved starts with an initial diagnostic
assessment, to intervention and consultation. Our speech and language
therapists work within the following domains:

• Articulation and phonological errors (sound production errors)
• Receptive language delay
• Expressive language delay
• Oral motor weakness and function difficulties
• Apraxia
• Hearing loss therapy
• Parkinson’s, aphasia, dementia (neurological disorders affecting

communication skills)
• Voice disorders
• Dyslexia
• Auditory processing disorders
• Specific language delay
• Autism
• ADHD
• TBI (traumatic brain injury)
• Cerebral Palsy
• Dysphagia (any kind of oral motor or pharyngeal disorder

causing feeding difficulties)
• NG tubes, OG tubes, PEGs
• Stuttering and fluency
• Mutism
• AAC (alternative augmentative communication)

Page 5 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

• Sensory Integration disorders
• The listening program and Interactive Metronome
• Pre-linguistic skills (turn-taking skills, eye contact, play,

attachment)
• Genetic/chromosomal syndromes, such as Down Syndrome
• Social Communication disorder
• Cochlear implant
• Literacy impairments/Learning difficulties

Occupational Therapy (OT)

Occupational Therapy is based on helping children and young adults acquire
and/or regain the skills needed to perform everyday tasks. For children, that
includes tasks that are part of learning and functioning well at school.

OT can help kids with various needs to improve their cognitive, physical,
sensory, and motor skills and enhance their self-esteem and sense of
accomplishment.
The aim of treatment is to improve fine and gross motor skills as well as motor
planning to name just a few.

Here are examples of the tasks and skills OTs might focus on:

• Self-care routines like getting dressed (fine motor skills and motor
planning)

• Writing and copying notes (fine motor skills, hand-eye coordination)
• Holding and controlling a pencil/pen, using scissors (fine motor skills,

motor planning)
• Throwing and catching (gross motor skills like balance and coordination)
• Getting the school bag ready (motor planning, organization skills)
• Reacting to sensory input (self-regulation skills)
• Change in routine

Therapy is child-specific, therefore no one child is the same, an assessment is
completed to identify strengths and challenges, from this a treatment plan and
goals are devised to help turn the challenges into developing skills.

Page 6 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Applied Behaviour Analysis Therapy (ABA)

Applied behaviour analysis (ABA) is the use of specific evidence-based
techniques and principles to bring about meaningful and positive changes in
behaviour. Behaviour analysis focuses on the principles that explain how
learning takes place. ABA has developed many techniques for increasing useful
behaviours (e.g., communication skills, language skills, play skills, social skills,
pre-linguistic skills, pre-academic skills, pre-learning skills and daily living
skills) and reducing those that may cause harm or interfere with learning (e.g.,
challenging behaviours, stereotypic behaviours). These techniques can be used
in structured situations, such as a classroom lesson, as well as in "everyday"
situations, such as family mealtimes or in a playground. A developmental and
behaviour assessment is conducted by the Behaviour Analyst, and an
individualised therapy plan is created. ABA therapy sessions can involve one-
on-one learning and group instruction. Our Behaviour Analyst and ABA
Therapists work within the following domains:

• Autism Spectrum Disorder
• Behaviour problems
• Language and communication delays and disorders
• Developmental delays and disorders
• ADHD
• AAC (alternative and augmentative communication)
• Genetic/chromosomal syndromes, such as Down Syndrome
• Pre-linguistic skills (turn-taking skills, eye contact, play,

attachment)
• Other learning difficulties
• Parent training
• Toilet training

Group Therapy

The therapists at your child’s school are able to offer group therapy where and
if applicable. These groups will incorporate the above-mentioned skills, but
rather in a social setting with other children who are of similar age and ability.
Please inquire with your child’s therapist if groups are available.

Page 7 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

General Information

If your child has previously received intervention from any discipline, please
inform your therapist, as well as provide available reports. Should your child
have had an assessment in the same area as recommendations within the past
6 months, please provide these reports to your therapist. Once these reports
have been provided and read, the therapist will state whether further
assessments are required, or if therapy can immediately commence. Your child
will receive either weekly or twice-weekly therapy at their school. This will be
discussed with you by your therapist dependent on your child’s needs.

Post assessment, your therapist will devise an ITP (individual therapy plan)
where goals and aims are set out for the therapy sessions based on the
assessment results. Your child will be given therapy on a “pull-out” system
within school hours. This means that your child will be retrieved from their
classroom and taken to the therapy room for 30-60 minute 1:1 therapy
sessions. At times, a therapy session will take place within your child’s
classroom in order to encourage inclusion; however, the in-class sessions will
be discussed with the teacher before the session.

Therapy sessions at school will continue throughout the academic year unless
discharge has been discussed between the therapist and parent(s), and the
discharge form completed. A meeting between the therapist and parent(s) will
be arranged should either the therapist advise that therapy can be
discontinued or should parents request that therapy is terminated.

Session Cancellation Policy

If your child will not be attending their regular therapy session, due to illness,
vacation, school activity/trip, please inform the therapist before 8am the day of
the therapy session. Should you wish to re-schedule the session, please inform
the therapist of this via email.

If the session is cancelled/re-scheduled after 8am but before the end of the
school day of the session, you will be charged 50% of the session fee. If the
session is cancelled after the close of the school day or the therapist is not
informed of the cancelled session, you will be charged 100% of the session fee.

Page 8 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Communication Book

All communication regarding your child’s therapy sessions will be written in
the communication book provided. This will include homework, session report,
suggestions and general communication. Thus, please ensure that this book is
brought to every session, and is signed by you once read.

Therapists are available via email where needed. Should you wish to meet with
the therapist, please email them to arrange this. Fees regarding the meetings
will be discussed dependent on the need of discussion.

Meetings

Your therapist will arrange a meeting with yourself to discuss your child’s
progress and ITP goals in July and December, the end of each term. The
therapist will try their utmost to include either your child’s teacher or head of
learning support in these meetings; however, due to various schedules, this
may not always be possible. These bi-yearly meetings will replace your child’s
session for that week and be charged accordingly. Should you request that you
either not have the meeting, or that you would like your child’s session to
continue over and above the meeting, please inform your therapist via email.
Please note, that any requested meeting, will be charged according to time.

Assessments and Reports

An assessment/evaluation is the first step in a successful intervention. These
allow the therapist the opportunity to establish the level of your child’s ability,
as well as areas of strength and weakness. All assessments are charged
according to your child’s age, and discipline of the therapist. The therapist will
discuss the cost of the assessment, time needed to complete assessment, and
the assessment date(s) prior to scheduling in the assessment time with your
child. Please inform your therapist of any assessments that have been
completed in the past 6 months, as well as provide the therapist with a copy of
the report,

The assessment fee is inclusive of a summary report, which will be discussed
with you after the assessment is completed. Please note, the report may take 7-
10 days to complete. Should you require an urgent report, please note that an
additional fee will be charged. Once the report is completed, the therapist will
contact you to arrange a feedback meeting. This feedback is inclusive of the
assessment fee. Should you request a more detailed report, a further report fee
will be charged.

Page 9 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Payment Policy and Packages
Payments for school-based therapy sessions are due prior to the session
commencement and are due to be paid for the month that the sessions are
provided. Please note that therapy sessions for each month will be charged for
and sessions will continue unless the therapy is terminated in writing, and the
therapy discharge form is signed.

Payments can be made via the below options:
Cash: You are able to pay cash either through your child’s communication
book OR at Neuropedia. Please note that any payment made through the
communication book must be placed in an envelope clearly marked with your
child’s therapist’s name and that all payments made via the communication
book are done at your own risk, and therapists will not be liable for any cash
that is misplaced.
Cheque: Cheque payments can be made through your child’s communication
book OR at Neuropedia. Please note that any payment made through the
communication book must be placed in an envelope clearly marked with your
child’s therapist’s name. Cheques need to be made out to NEUROPEDIA CHILD
NEUROSCIENCE CENTER LLC
EFT: The below information would need to be provided to your bank should
you wish to pay via EFT:

Account no: 1271321993133016
IBAN: AE650271271321993133016
Account Name: NEUROPEDIA CHILD NEUROSCIENCE CENTER LLC
Bank Name: FAB
Swift Code: FGBMAEAA
Credit card: These payments can only be made at Neuropedia

Page 10 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Upfront Packages payments and Pricing

We offer package sessions in which you are able to purchase 10 or 20 sessions
and receive relevant discounts. Should you wish to purchase a package, please
inform your child’s therapist, or contact the reception at Neuropedia. All
packages are required to be paid upfront in order to receive the discount. We
are unable to back-date sessions to include in packages. If you start therapy
without purchasing the package, discount will not be applicable, and those
sessions will be charged at full price. ITP meeting sessions will come part of the
upfront payment package. Please note, the packages are to allow for discounts
and are NOT a prescription for the number or length of sessions your child
requires.

• Assessment fee will be discussed with you by the therapist as it is
dependent on assessment tools required and time allocated.

• School therapy session 30 minutes – 275/- AED
• School therapy session 45 minutes – 350/- AED
• School therapy session 60 minutes – 500/- AED
• School therapy session 30 minute 10 session package – 2,450/- AED
• School therapy session 45 minute 10 session package – 3,150/- AED
• School therapy session 60 minute 10 session package – 4,500/- AED
• Progress report fee – 510/- AED per hour
• Educational Assessment – 4500/- AED

Confidentiality

All information pertaining to you, your child and your family will remain
confidential. Information shared with your child’s teacher and school, will only
be done with your permission (please see attached Medical Release form).
Should you request that information is not shared with your child’s teacher
and school, please inform the school of this. Please note, should your child be
referred to any therapist at Neuropedia, the information will be shared with
said therapist.

Page 11 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

GLOSSARY

Inclusion team: The Inclusion Team are teachers within the school (previously the Special
Educational Needs and Disabilities or SEND Service) that advises and supports parents, and
families with the additional needs of children. They coordinate and provide support in the school
ensuring the child gets full access to education.

Therapy team: A group of therapists who provides therapy for children with additional needs.
(This could be OT, PT, SLT, ABA, Dietetics and Psychology).

Identified Needs: Identified needs means teachers/parents have established the child is not
performing to the expected standard for their peer age group. Identified needs also means a
therapist has established a child requires additional support in a particular area.

Informed Consent: A process of communication between a parent and a therapist or the clinic
that results in the parents’ authorization or agreement for the child to undergo a specific
Intervention with a full understanding of the process.

Informal Observation/ Class Observation: Informal Observation is a natural way of observing
a child's skills and development within a familiar context. The therapist collates qualitative data
about a child’s performance, looking at areas of Physical, Emotional, Cognitive Play and Social
Development. This is then compared to what would be expected of peers.

Assessment: Standardized procedure to establish needs based on current level of
performance of the child within one particular field. For example, Articulation and Fluency within
a Speech and Language Assessment. (This service to is to be paid for by the parent).

Screener: A screener is completed as a preliminary step to detect if the need for a full
assessment is required. For example, a basic Occupational Therapy screener can be completed
to establish if a full OT Assessment is required. (This screener is offered to schools that have a
direct contact with Neuropedia).

ITP: Individual Therapy plan - A written Individualized Therapy plan. The Plan is
a comprehensive, progressive, personalized plan that includes all the identified needs and
strategies that will be utilized by the therapist to help address the above needs. It is person-
centered and is driven by the patient and the family’s goals.

IEP: Individual Educational plan - A written individualized Educational plan. The Plan is
a comprehensive, progressive, personalized plan that includes all the identified needs and
strategies that will be utilized by the school to help address the above needs. It is person-
centered and is driven by the patient and the family’s goals.

Therapy: A therapy is the attempt to provide intervention when a need or a medical diagnosis
has been made. The aim of therapy is to make change that enhances Health, Behavior,
Communication, Gross Motor Development, Social skills and Play to name just a few.

Page 12 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Therapy Referrals

InclusIinocnluTseioanmTIedaemntifies
IdentTihfiersaTphyeNraepeydNs eeds

Yes No

Straight to Discipline or Stop Consent for Informal
Assessment No Observation (IO)

Yes

IO Completed
Needs Identified.

Yes

Consent for Assessment

Stop No Yes Assessment Payment

Complete Assessment
Therapy Recommended

Yes Therapy Payment

ITP is created from
assessment results

Therapy sessions
commence

Therapy progress is
reviewed with parents
and teacher twice a year

Page 13 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

INFORMED CONSENT
Informal observation (classroom)

I, __________________________________________________ (parent/caregiver name), give
permission that my child, _________________________________ (child’s name) have a
recommended classroom observation conducted by Neuropedia clinicians. I
acknowledge that this observation is not a formal assessment and is a free 10-15-
minute informal observation of my child’s abilities shown within the classroom
setting.

The observation is carried out by a trained health care professional (OT, PT, SLT,
Psychologist, or Behavioural therapist). The observation is a holistic approach whereby
we observe the child, identifying any ‘areas of concern’, these finding allow the therapist
to determine if therapy support is needed and in what form.

The therapist will discuss a suitable time with the class teacher to observe the child,
and then provide a short summary of what was observed, including recommendations,
to the SEN department of the school.

I acknowledge and consent to information being shared with the school, and the multi-
disciplinary team of therapists at Neuropedia. I know that the information will NOT be
shared with any other entity or person.

_______________________________________ __________________________
(Parent/caregiver signature) (Date)

Page 14 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

INFORMED CONSENT
ASSESSMENT

I, _________________________________________________parent/caregiver name),
have been informed of the terms of a diagnostic assessment, including the fees.
I thus give permission that my child, _________________________________ (child’s
name) have the recommended diagnostic assessment:
_______________________________________ (type of assessment). I also agree to
pay for the assessment prior to the date scheduled with the therapist and the
school.

______________________________________________ ________________________
(Parent/caregiver signature) (Date)

Page 15 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

INFORMED CONSENT
THERAPY

I, _______________________________________________(parent/caregiver name), have
been informed by the therapist regarding all the terms of school therapy,
including the fees. I would thus like my child
___________________________________ (child’s name) to begin school therapy with
_______________________________________ (therapist’s name). I understand and

agree that therapy will take place ______ a week for ______ minutes each session.

I understand that therapy sessions will continue unless I request that my child’s
therapy be terminated, or the therapist advises that my child can be discharged
from therapy.

I agree to pay for therapy sessions directly to Neuropedia within the month, and
that should payment not be made, that my child’s therapy may be suspended.

______________________________________________ ________________________
(Parent/caregiver signature) (Date)

Page 16 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

MEDICAL RELEASE FORM

I, __________________________________________________________
(parent/caregiver’s name),

give consent / do not give consent for Neuropedia to contact my child’s school
and their teacher/s

to have either written or verbal communication regarding my child.

I also give/do not give permission for the therapists to give a copy of my child’s
reports to the

school and/or access my child’s school files.

______________________________________ (child’s name)

______________________________________ (child’s class teacher name)

______________________________________________ ________________________
(Parent/caregiver signature) (Date)

Page 17 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

SCHOOL THERAPY SESSION CANCELLATION AND THERAPY
DISCHARGE POLICY

Should your child be sick, or not be able to attend the session, please inform
the therapist via email before 8:00am the day of the session.

Alternatively, please call Neuropedia reception the day prior to your child’s
session to inform them that your child will not be attending the session at
school the next day.

Should you cancel the session late, you will be charged 50% of the session fee.
Should the session not be cancelled by the start of the session time, you will be
charged 100% of the session fee.

______________________________________________ ________________________
(Parent/caregiver signature) (Date)

If you wish to terminate therapy prior to the recommendations of the therapist,
Neuropedia requires that this is stipulated in writing to the therapist;
otherwise, therapy sessions will continue.

______________________________________________ ________________________
(Parent/caregiver signature) (Date)

Page 18 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

Patient Name: ____________________________

EMR:___________________________________

Nationality:______________________________

DOB:___________________________________

Sex : Male Female

Patient ID Number: Passport Emirates ID Other
______________
___________________ _________

PATIENT DETAILS

FULL NAME : ____________________________________________ Date of Visit : ___________________

Gender : Male Female Date of Birth : ____________________________

Nationality : ______________________

Home Address : ____________________________________________________________________________

REFERRING DOCTOR AND/OR CLINIC/HOSPITAL: _________________________________________
REFERRED TO: ___________________________________________________________________________

CONTACT DETAILS

Father’s Name : ___________________________ Mother’s Name : ___________________________

Phone Number : ___________________________ Phone Number : ___________________________
Email Address : ___________________________ Email Address : ___________________________
Place of Employment : ______________________ Place of Employment : ______________________
Occupation : ___________________________ Occupation : ___________________________

RESIDENCY STATUS

Emirati Resident Expatriate Tourist Visa

CITY: Abu Dhabi Dubai Sharjah Ajman Um m Al Quwain

Ras Al Khaimah Fujairah

Country of Residence (Mandatory) _________________________________________________________

SELF – PAY MODE OF PAYMENT OTHER (Specify) ________
INSURANCE

Page 19 of 20
24, opp. Dubai Zoo, Beach Road. P.O.Box: 333685, Jumeirah 1, Dubai, UAE.

Tel: 04 343 1113

GENERAL CONSENT FORM

‫استمارة موافقة عامة‬

Dear Guest, ،‫ضيفنا العزيز‬
We welcome you to Neuropedia, Childrens Neuroscience Center (CNC) :‫ نود إعلامكم بما يلي‬، )CNC ( ‫نرحب بك في مركز نيوروبيديا لطب أعصاب الأطفال‬
and we would like to inform you of the following:
‫الموافقة العلاجية‬
Treatment Consent ‫ كما أقر أيضاَ بأن‬.CNC ‫أوافق فيما يلي على تلقي العلاج من قبل الفريق الطبي في مركز‬
I hereby consent to be treated by the medical staff of CNC. I also acknowledge
that this consent is subject to the laws and jurisdiction of the United Arab .‫هذه الوثيقة خاضعة لقوانين و الولاية القضائية لدولة الإمارات العربية المتحدة‬
Emirates.
‫ وبأنني‬، ‫علاوة على ذلك؛ أقر بأنني استلمت نسخة من قائمة حقوق ومسؤوليات المريض‬
Furthermore, I acknowledge that I have received a copy of the Patient’s Rights ‫سوف أكون مسؤولاً عن متعلقاتي الشخصية خلال تواجدي في مركز نيويروبيديا لطب‬
and Responsibilities and that I will be responsible for my belongings during .‫أعصاب الأطفال‬
my presence in Neuropedia, Childrens Neuroscience Center.
‫الموافقة المالية‬
Financial Agreement ‫ سوف أتولى المسؤولية الشخصية‬،‫خلال الفترة الزمنية المتوقعة لزيارة أو إقامة فرد الأسرة‬
Within the expected time frame during my/family member’s visit or stay. I .‫ بغض النظر عن صيغة او مصدر الدفع‬CNC ‫لسداد جميع الإلتزامات المالية تجاه مركز‬
will take personal responsibility and meet my financial obligations towards
CNC regardless of the mode and source of payment. (Self-paying, Sponsoring )‫الخ‬...‫ ضمان شركات‬,‫( دفع نقدي‬
Company, etc.)
‫ سيتم اقتطاع الدفعة المقدمة كجزء من الرسوم‬،‫في حال تحديد قيمة تقديرية للتكاليف‬
In cases where an estimated charge has been given, the deposited amount is ‫ وإنني أعلم بأن القيمة التقديرية المعطاة قد تختلف عن قيمة‬.‫المستحقة أو كنسبة منها‬
utilized against accrued charges or a proportion of the same. I take note that ‫ نحن‬/‫ أنا‬,‫ في حال وجود اختلاف في التكلفة‬.‫الحساب النهائي وفقاَ للخدمات الفعلية المقدمة‬
an estimated charge has been given which may differ from the final account
depending on the actual services rendered. If there is a difference in the cost, .‫سوف نكون مسؤولين عن تسديد هذه التكاليف‬
I/We will be responsible for the settlement of these costs.
‫نشر المعلوامات الطبية‬
Release of Medical Information CNC ‫ فإنني أمنح موافقتي للجهات المسؤولة في مركز‬،‫بعد إتمام بيانات هذه الاستمارة‬
On completion of this form, I direct the authorities in CNC to release necessary ‫بتقديم أية معلومات ضرورية لشركة التأمين التي اتعامل معها أو لأي طرف ثالث سيقوم‬
information to my insurance carrier or third party payer (if applicable) for the ‫ بغرض تحديد الجهة المستحقة للدفع والقيام بالإجراءات‬،)‫بدفع التكلفة (في حال وجوده‬
purpose of determining benefit entitlement and to process payment, therefore
taking responsibility for the .‫اللازمة لتسوية الفواتير الطبية‬
financial settlement of the medical bills.
‫خدمات المختبر‬
Laboratory Services ،‫أنا على علم بأنه بناءاَ على تعليمات الطبيب المعالج قد يتم سحب عينات من الدم او البول‬
I am aware that on clinician’s test order my blood, urine or other clinical
samples will be sent to referral labs for the tests not performed within CNC. ‫أو أية عينات أخرى وسيتم إحالتها لمختبرات طبية خارجية حيث لايتم إجراء مثل هذه‬
. CNC ‫الفحوصات ضمن‬
Personal Valuables
I understand and agree that CNC will not be held liable or have any ‫المتعلقات الشخصية‬
responsibility if there should be any loss or damage to my Valuables. ‫ لن يكون عرضة لأي مسائلة ولا يتحمل أي مسؤولية‬CNC ‫أتفهم وأوافق على ان مركز‬

.‫في حالة فقدان او إتلاف أي من المتعلقات الشخصية‬

“I fully understand the contents of this General Consent Form and agree to its ‫ هذه الموافقة‬.‫" أتفهم محتويات استمارة الموافقة العامة هذه واوافق على جميع شروطها‬
terms. This General Consent to Treatment and Authorization for Release of ‫العامة للعلاج والتفويض على نشر المعلومات الطبية سوف تنتهي بتاريخ ــــــــــــــ‬
Medical Information will expire on ______________________.
‫ حدث او شرط لانتهاء فعالية التفويض للاتفاقية‬،‫في حال لم اتمكن من تحديد تاريخ محدد‬
If I fail to specify an expiration date, event, or condition of this authorization ‫العامة للعاج والتفويض بنشر المعلوامت الطبية فإن هذه الوثسقة سوف تنتهي خلال سنة من تاريخ‬
for General Consent to Treatment and Authorization for Release of Medical
Information will expire in one (1) year from the date of signing.” .‫التوقيع‬
Children below 16 should be accompanied by a parent or a carer.

Name / Guardian : ______________________________ Guardian/ Relationship to Patient : ________________________

--------------------------------------------- :‫ صلة القرابة للمريض‬------------------------------------------------ :‫إسم الوصي‬

Signature : _____________________________________ Witness: _____________________ Date : ___________________

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