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Natural Cleft Form

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NATURAL CLEFT AGREEMENT

This Natural Cleft Agreement (the Agreement) is entered into as of Effective Date: by and between Service Provider: and Client: .

Recitals

WHEREAS, Service Provider is engaged in the development, manufacture and distribution of natural and clinical protocols and products specifically designed for non-surgical care related to cleft conditions (Natural Cleft Services and Products); and

WHEREAS, Client desires to engage Service Provider to perform the services and/or supply the products described in this Agreement, and Service Provider agrees to provide such services and products in accordance with the terms and conditions set forth herein; and

WHEREAS, the parties desire to set forth their rights and obligations with respect to the provision of Natural Cleft Services and Products.

Scope of Work

Service Provider shall provide the services and supply the products described below in accordance with the terms of this Agreement. The description below is intended to be a comprehensive statement of deliverables, milestones and acceptance criteria.

Payment Terms

Client shall pay Service Provider the compensation set forth below in consideration for the performance of the Scope of Work. All payments shall be payable in United States dollars unless otherwise agreed in writing.

In the event any undisputed amount is not paid within days after the invoice due date, Client shall pay a late fee equal to per month on the overdue balance, calculated monthly until paid in full. Service Provider may suspend performance for amounts outstanding beyond days after written notice.

Term and Termination

This Agreement shall commence on Start Date: and continue until End Date: unless earlier terminated in accordance with this Section.

Either party may terminate this Agreement for convenience upon days prior written notice to the other party. Upon termination for convenience, Client shall pay Service Provider for all work performed and products delivered and accepted through the effective date of termination.

Either party may terminate for material breach if the breaching party fails to cure the breach within 30 days after receipt of written notice specifying the breach. Termination for material breach shall be in addition to any other rights or remedies available at law or in equity.

Confidentiality

Each party (the Receiving Party) shall hold in strict confidence all non-public information disclosed by the other party (the Disclosing Party) that is identified as confidential or that, by its nature, would reasonably be understood to be confidential, including but not limited to product formulations, clinical protocols, patient-related information, pricing, business plans, and technical data (Confidential Information). The Receiving Party shall: (a) use Confidential Information solely for the performance of this Agreement; (b) restrict disclosure to employees, contractors or agents with a need to know and who are bound by confidentiality obligations at least as protective as this Section; and (c) take reasonable measures to protect Confidential Information from unauthorized use or disclosure.

Confidential Information shall not include information that: (i) is or becomes generally available to the public other than through a breach of this Agreement; (ii) was rightfully in the Receiving Party's possession prior to disclosure by the Disclosing Party; (iii) is received from a third party without breach of an obligation of confidentiality; or (iv) is independently developed by the Receiving Party without use of the Disclosing Party's Confidential Information. Confidentiality obligations shall survive termination or expiration of this Agreement for a period of five (5) years, except for trade secrets, which shall remain protected for as long as they qualify as trade secrets under applicable law.

Representations and Warranties; Limitation of Liability

Service Provider represents that it will perform services in a professional manner consistent with industry standards and applicable laws. EXCEPT AS EXPRESSLY PROVIDED HEREIN, SERVICE PROVIDER MAKES NO OTHER WARRANTIES, EXPRESS OR IMPLIED, INCLUDING WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. IN NO EVENT SHALL EITHER PARTY BE LIABLE TO THE OTHER FOR INDIRECT, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, AND EACH PARTY'S AGGREGATE LIABILITY ARISING OUT OF OR RELATED TO THIS AGREEMENT SHALL NOT EXCEED THE AMOUNTS PAID OR PAYABLE BY CLIENT TO SERVICE PROVIDER UNDER THIS AGREEMENT IN THE TWELVE (12) MONTHS PRECEDING THE CLAIM.

Notices

All notices required or permitted to be given under this Agreement shall be in writing and shall be deemed delivered when delivered in person, sent by certified mail (return receipt requested), or sent by nationally recognized overnight courier to the addresses set forth below or to such other address as either party may designate by notice to the other.

Governing Law; Dispute Resolution

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. The parties agree to attempt in good faith to resolve any dispute arising out of or relating to this Agreement through negotiation between senior representatives. If the parties are unable to resolve the dispute through negotiation within thirty (30) days, the dispute shall be submitted to binding arbitration before a single arbitrator in the county of the governing law state, with the arbitrator applying such state's substantive law.

Entire Agreement; Amendment

This Agreement, together with any exhibits or attachments expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous understandings, proposals and agreements, whether written or oral. This Agreement may be amended or modified only by a writing executed by authorized representatives of both parties.

Miscellaneous

Neither party may assign this Agreement without the prior written consent of the other, except that either party may assign this Agreement in connection with a merger, acquisition or sale of substantially all of its assets. The invalidity or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision, and the parties shall negotiate in good faith to replace any invalid or unenforceable provision with a valid provision that achieves, to the greatest extent possible, the original economic intention.

Certifications

Each party warrants that it has the full corporate or individual power and authority to enter into this Agreement and to perform its obligations hereunder. Each party further certifies that it will comply with all applicable laws, regulations and professional standards in performing its obligations under this Agreement.

Service Provider:

By:

Date:

Client:

By:

Date:

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What the Natural Cleft Form is and where it’s used

The Natural Cleft Form is a standardized healthcare intake and clinical documentation template used to record diagnosis, treatment planning, caregiver information, and informed consent related to cleft lip and palate conditions. Providers use it to capture medical history, physical findings, speech and feeding assessments, imaging references, and treatment options. The form supports clinical continuity across multidisciplinary teams (surgery, speech therapy, pediatrics, dentistry) and can be adapted for intake, preoperative assessment, or long‑term follow up while preserving a clear audit trail of decisions and signatures.

Why a clear Natural Cleft Form matters for care and compliance

A complete, structured Natural Cleft Form improves care coordination, documents informed consent, and reduces administrative follow‑up. Standardized fields decrease errors and support billing, prior authorization, and quality metrics while helping meet recordkeeping obligations under healthcare regulations.

Why a clear Natural Cleft Form matters for care and compliance

Typical users and parties who complete the form

The Natural Cleft Form is completed by clinical teams and administrative staff to capture consistent patient and treatment data before and after visits.

  • Pediatric surgeons and craniofacial teams — document diagnosis, surgical plans, and postoperative instructions for multidisciplinary coordination.
  • Speech and feeding therapists — record functional assessments, therapy goals, and progress notes used in care plans.
  • Clinic administrators and intake staff — verify patient identity, insurance details, and consent status prior to procedures.

Clear role separation—who enters clinical details, who verifies identity, and who signs—reduces errors and supports legal validity.

Core components to include in a professional Natural Cleft Form

A professional Natural Cleft Form groups clinical findings, administrative data, consent language, and signature zones so every required item is visible and auditable at each care stage.

Patient Identifiers

Full legal name, date of birth, medical record number, and primary caregiver contact to ensure correct patient matching across systems.

Clinical History

Relevant prenatal, perinatal, and feeding history plus previous surgeries, complications, comorbidities, and current medications for safe planning.

Assessment Findings

Document physical exam details, cleft classification, speech evaluation notes, imaging references, and baseline functional measurements.

Treatment Plan

Planned interventions, alternatives, estimated timelines, follow‑up schedule, and responsibilities for multidisciplinary team members.

Informed Consent

Clear, specific consent language covering risks, benefits, alternatives, and signature blocks for legal and clinical clarity.

Audit & Attachments

Section for attached images, scanned reports, referral letters, and an audit trail showing who viewed and signed each element.

Required form fields and essential data elements

Patient Name: Full legal name
Date of Birth: MM/DD/YYYY
MRN / ID: Medical record number
Caregiver Contact: Phone and email
Diagnosis Code: ICD-10 code
Signature: Signed and dated

Step-by-step: completing the Natural Cleft Form

Follow these core steps to complete the form accurately and preserve legal validity for clinical and billing purposes.

  • 01
    Collect ID: Verify patient identity using government-issued ID.
  • 02
    Enter Clinical Data: Record history, assessment, and diagnosis clearly.
  • 03
    Present Consent: Explain risks, benefits, and alternatives to caregiver.
  • 04
    Obtain Signature: Capture signature and date with witness if required.

How to configure a digital Natural Cleft Form workflow

Configure these settings to match clinical review order, authentication requirements, and storage destination.

File Type PDF or DOCX for EHR import
Field Types Text, date, checkbox, signature fields
Authentication Email OTP, SMS code, or KBA as needed
Routing Sequential routing to clinician then admin
Notifications Email reminders and completion receipts

Where to send the completed Natural Cleft Form

Define routing points so each stakeholder receives the version they need and the record is archived in the right system.

  • Electronic Health Record: Archive signed PDF in the patient chart
  • Referring Provider: Send a copy to the referring clinician
  • Caregiver Copy: Provide a signed copy to the caregiver
  • Billing / Authorization: Forward procedure and consent details

Technical considerations for eSubmission and integrations

Ensure the chosen platform supports required authentication, secure storage, and the integrations used in your clinic.

  • EHR Integration: FHIR / HL7 support recommended
  • Cloud Storage: Google Drive, Box, or Procore
  • API & SSO: SSO and REST API access

Typical timelines and scheduling considerations

Track timing for authorizations, preop clearance, and signature validity to avoid scheduling delays and denials.

Intake Completion:

Complete at least 7 days before appointment

Insurance Authorization:

Allow 7–21 days for prior authorization

Surgical Scheduling:

Book 4–12 weeks depending on availability

Postoperative Follow-up:

Schedule initial follow-up 1–2 weeks post op

Record Corrections:

Submit amendments promptly to prevent billing issues

Common mistakes to avoid when preparing the form

  • Entering abbreviated names or nicknames that do not match identity documents, causing verification delays and billing mismatches.
  • Leaving diagnosis or procedure codes blank, which can lead to claim denials or incorrect authorization routing.
  • Missing caregiver language preference or interpreter needs, which undermines informed consent and may invalidate the signature.
  • Failing to attach relevant imaging or reports, forcing duplicate requests and slowing clinical decision making.

Consequences of incorrect or incomplete Natural Cleft Forms

Billing Denials: Delayed or denied reimbursement
Consent Invalidity: Legal exposure for the provider
HIPAA Risk: Privacy breach potential
Care Delays: Treatment postponement
Credentialing Issues: Provider documentation gaps
Malpractice Exposure: Increased litigation risk

Typical eSignature vendor pricing and capability snapshot for clinical forms

Compare starting prices and common capability markers for routine clinical eSignature workflows; signNow is listed first as the baseline platform option.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (Business Premium) Yes Yes Yes Limited
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA) Yes (BAA) Yes (BAA) No No

Real-world examples of electronic form use in clinical settings

These examples illustrate how clinics and care teams use digital forms to streamline intake, consent, and recordkeeping workflows.

Fertility Centers of Illinois

A mid‑sized clinic replaced paper intake with a digital form to centralize records and reduce errors.

  • Implementation simplified EHR uploads and automated reminders.
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Martin Properties (clinic partner)

A community clinic adopted digital consent to reduce in‑office time and missed signatures.

  • Staff used templates for consistent language across clinics.
  • "I can process and execute all of these documents online with 100% compliance and built-in security."

Frequently asked questions about completing and signing the Natural Cleft Form

Answers to common issues encountered when preparing, signing, or storing the Natural Cleft Form in U.S. clinical settings.


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