CONSENT TO MEDICAL CARE. I hereby authorize the health care providers of Drip Hydration (“the Practice”) and their staff, to perform any medical diagnostic procedures and medical care which in their professional judgment is deemed necessary to diagnose and/or treat the conditions that have brought about my seeking medical care services from the Practice. I acknowledge that no guarantees are made to me concerning the outcomes of the treatment rendered by the health care providers of the Practice.
I understand that the terms herein are contractual and not a mere recital; and that I sign this document as my own free act and void of any coercion. I also understand and acknowledge that I have the right to request and receive a copy of this agreement at any time from the Company. The permissions granted herein shall begin on the date listed below and shall remain effective until terminated by the undersigned except for the financial agreement and guarantee, governing law, severability and mediation and arbitration sections herein, which cannot be terminated. My signature below verifies that I have read all of the information contained in this agreement and asked questions about anything I have not understood up to this point.
CONSENT TO MEDICAL CARE:
I hereby authorize the health care providers of Drip Hydration (“the Practice”) and their staff, to perform any medical diagnostic procedures and medical care which in their professional judgment is deemed necessary to diagnose and/or treat the conditions that have brought about my seeking medical care services from the Practice. I acknowledge that no guarantees are made to me concerning the outcomes of the treatment rendered by the health care providers of the Practice.
FINANCIAL AGREEMENT AND GUARANTEE:
I accept full and complete financial responsibility for all medical services rendered to me and agree to pay for the services in full within 7 days of receiving testing. I further acknowledge, understand and agree that in the event that I fail to make such payments in accordance with the payment policies of the Practice, or in the event of default of my financial obligation to pay for services rendered, the Practice may terminate the “doctor-patient” relationship with me. Furthermore, in the event of my default of my financial obligation, should my account be turned over to an external collection agency for non-payment, I agree to pay any associated collection costs. I understand that the terms herein are contractual and not a mere recital; and that I agree to this document as my own free act and void of any coercion. The permissions granted herein shall begin on the date of acceptance and shall remain effective until terminated by the undersigned. By agreeing to this document I verify that I have read all of the information contained in this Medical Consent Form and that I have asked questions about anything I have not understood up to this point.