Health Care Waiver Agreement

HEALTH CARE WAIVER AGREEMENT

This Health Care Waiver Agreement ("Agreement") is entered into as of Effective Date: by and between Provider Name: with principal address and Patient Name: , Date of Birth: , residing at .

RECITALS

WHEREAS, Provider is engaged in the business of delivering health care services, including but not limited to clinical consultation, diagnostic testing, therapeutic procedures and other services described in Section 2; and

WHEREAS, Patient desires to receive certain health care services from Provider and acknowledges that such services may involve risks, complications, or unforeseen outcomes; and

WHEREAS, the parties intend by this Agreement to define the allocation of risks, to obtain Patient's informed waiver of certain claims, and to establish indemnity and release obligations to the extent permitted by applicable law.

NOW THEREFORE, in consideration of the mutual covenants and promises contained herein and for other good and valuable consideration, the sufficiency of which is hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, the following terms shall have the meanings set forth below:

"Services" means the health care services, procedures and treatments to be provided to Patient, including those described here:

"Claims" means any claim, demand, cause of action, suit, liability, damages, loss, cost or expense, including reasonable attorneys' fees and costs, arising out of or in connection with the Services or the performance of this Agreement.

2. DESCRIPTION OF SERVICES AND CONSENT

Provider shall provide the Services described above in accordance with generally accepted professional standards. Patient acknowledges receipt of an explanation of the nature and purpose of the Services, the anticipated benefits, reasonable alternatives (if any), and the material risks involved, and hereby consents to the Services.

3. ACKNOWLEDGMENT OF RISKS; WAIVER

Patient acknowledges that the Services may involve risks which include, but are not limited to, infection, bleeding, allergic reaction, scarring, complication, failure to achieve expected results, and other adverse outcomes. Patient voluntarily assumes all such risks to the maximum extent permitted by law.

To the extent permitted by applicable law, Patient hereby waives, releases and discharges Provider, its affiliates, employees, officers, directors, agents and contractors (collectively "Released Parties") from any and all Claims arising out of or relating to the Services, whether foreseen or unforeseen, except for Claims resulting solely from gross negligence or willful misconduct of Provider.

4. REPRESENTATIONS AND WARRANTIES

Patient represents and warrants that Patient has disclosed all known medical conditions, medications, allergies and prior treatments that could affect the Services. Patient further represents that Patient has the legal capacity to consent to the Services or is signing as an authorized representative.

If Patient is signing as an authorized representative, check the box and provide relationship and authority documentation:

Representative is signing on behalf of Patient

5. RELEASE AND INDEMNIFICATION

To the fullest extent permitted by law, Patient shall indemnify, defend and hold harmless the Released Parties from and against any and all Claims arising out of Patient's acts or omissions, negligent or intentional misrepresentations, or breach of this Agreement. This indemnity obligation survives termination or completion of the Services.

6. LIMITATION OF LIABILITY

Except for liability arising from Provider's gross negligence or willful misconduct, Provider's aggregate liability to Patient for Claims arising out of or relating to the Services shall be limited to direct damages not to exceed the total amounts actually paid by Patient to Provider for the specific Services that gave rise to the Claim.

7. MEDICAL RECORDS AND PRIVACY

Provider shall maintain Patient's medical records in accordance with applicable privacy and medical records laws. Patient authorizes Provider to use and disclose medical information as necessary for treatment, billing, quality assurance and legal compliance. Patient may request copies of records in writing as permitted by law.

8. NOTICES

Any notice required or permitted by this Agreement shall be in writing and delivered to the addresses set forth in the opening paragraph or to such other address as a party designates in writing. Notice shall be deemed given upon personal delivery, three days after deposit in the United States mail with first class postage prepaid, or one day after deposit with a commercial overnight carrier.

9. AMENDMENT; WAIVER

This Agreement may be amended only by a written instrument signed by both parties. No waiver of any provision shall be effective unless in writing and signed by the party waiving compliance. A waiver of one breach shall not operate as a waiver of any subsequent breach.

10. COUNTERPARTS; ELECTRONIC SIGNATURES

This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Signatures delivered by electronic means shall be deemed original signatures and binding for all purposes.

11. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state or jurisdiction in which Provider maintains its principal place of business, without regard to conflict of law rules that would result in the application of the laws of another jurisdiction.

12. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings. If any provision of this Agreement is held invalid or unenforceable, that provision shall be reformed only to the extent necessary to make it valid and enforceable, and the remaining provisions shall continue in full force and effect.

MISCELLANEOUS INFORMATION

By signing below, Patient acknowledges that Patient has read this Agreement in its entirety, understands its terms, has had an opportunity to ask questions and has freely and voluntarily agreed to its terms.

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