PATIENT WAIVER AND RELEASE AGREEMENT
FOR PATIENTS OF
AMERICAN MEDICAL GENERAL, INC.
FOR PATIENTS OF
American Medical General, Inc. (hereafter ďAmerican MedicalĒ or ďAMGĒ) and the †individual who purchases a medical treatment from AMG or paid for the treatment of another by AMG †(hereafter ďPatientĒ) enter into this ĎPatient Waiver of Claims and Informed Consent Agreementí (hereafter ďAgreementĒ) in consideration of the promises contained herein and other agreed adequate consideration. The Parties understand, accept and agree to all the terms, conditions and provisions of this Agreement on the date Patient indicates acceptance of this Agreement by electronic signature on the internet or otherwise.
I, the undersigned Patient, accept, understand, and agree to the following terms, provisions and conditions:
a. Patient understands that American Medical is a medical Patient medical services management corporation managing and coordinating the medical services, physician services, laboratory services, pharmacy services, other services, prescription drugs and products provided Patient by independent contractors, physicians, medical organizations, diagnostic medical laboratories, pharmacies and other individuals or entities in the United States of America on behalf of American Medical.
2.†††††††††††††† INDEPENDENT CONTRACTORS OF AMERICAN MEDICAL
b. Independent contractors and medical organizations that may provide medical services, prescription drugs, other services and products to Patient on behalf of American Medical include, but are not limited to the following:
1) Physicians and medical organizations conducting Patientís physical examination;
2) Diagnostic medical testing laboratories;
3) Physicians who evaluate Patient physical exam results, medical history, medical complaint and prescribe medication or medical treatment;
4) Pharmacies that dispense prescribed medication directly to Patient; and,
5) Personal physical fitness trainers who provide fitness training to Patients enrolled in the Platinum medical weight loss, diet and fitness program.
3.†† ††††††††† NATIONAL MEDICAL SERVICES AND PRODUCTS PROVIDED: PHYSICAL EXAMINATION, PRESCRIBING OF TREATMENT, DISPENSING PHARMACY AND SUPERVISION OF PATIENT MEDICAL TREATMENT†
a. American Medical shall provide Patient with appropriate medical services, physician services, medical laboratory services, medical treatments, pharmacy services, diet programs, other services and products purchased from American Medical by Patient by managing, coordinating and purchasing such services and products from independent medical, laboratory and pharmacy contractors that provide such services and products to Patient.
b. American Medical may fulfill its responsibilities under this Agreement by delegating its contractual obligations due Patient to one or more contracting organizations or individuals for the purposes of providing Patient services and products purchased through American Medical.
c. The physical examination of Patient shall be performed by a licensed physician located within sixty miles of the location of the residence or employment location of Patient. American Medical shall provide this physician at its expense. The physician conducting the examination must provide American Medical with the following American Medical physical exam forms within one week of the exam date as a prior condition to the Patient receiving the discounted amount in consideration of the Patient providing the physician to conduct Patientís physical examination:
1) American Medical - Physical Exam Report
2) American Medical - Medical History Report
3) American Medical - Examining Physician Acknowledgement Form
d. The physician conducting the physical examination of Patient, or other physician within the medical organization employing the examining physician if the examining physician is not available, shall be responsible for supervising medical treatments prescribed by independent contracting physicians or employee physicians of American Medical.
e. Patient agrees that the physician performing the physical examination of Patient and supervising treatment of Patient shall not provide any urgent or emergency medical care to Patient with regard to any urgent or emergency medical condition that arises from any treatment prescribed by an independent contracting or employee physicians of American Medical. Patient go agrees to go directly to the nearest hospital emergency room in the event of an urgent or emergency medical condition arising from any American Medical program or treatment adversely affecting Patient.†
f. Patient agrees to undergo a medical laboratory urine or blood test if required for the American Medical treatment program purchased.
g. Independent contracting or employee physicians of American Medical shall evaluate the physical exam report, medical history report, any laboratory test report and the medical complaint of Patient in determining whether or not to issue a prescription for a medical treatment requested by Patient.
h. There must be a logical relationship between Patientís medical complaint and any drug prescribed for Patient.
i. If the independent contracting physician or employee physician of American Medical declines to issue a prescription for medical treatment sought by Patient, the purchase amount shall be refunded in full to Patient if American Medical has received payment.
a. Patient agrees to immediately go to the nearest hospital medical emergency room at the time of any type of medical emergency or medical condition that Patient believes requires the immediate medical attention with regard to any medical emergency or medical condition which arises from any treatment, service, product or prescription drug provided by American Medical or any employee, agent, independent contractor, contracting medical organization, independent physician, independent medical laboratory, independent pharmacy or any other individual or organization rendering Patient services on behalf of American Medical.
b. Patient understands that American Medical and its physician employees, independent contracting physicians, agents and organizations providing medical services at the request of American Medical to Patient DO NOT PROVIDE EMERGENCY MEDICAL SERVICES.† Such agents, independent contractors, and organizations providing services to Patient at the request of American Medical include, but are not limited to, the following: any employee, officer or director of American Medical; and any individual, partnership, corporation or other legal entity providing medical services, physician services, physical exam services, physician prescribing services, medical diagnostic laboratory services, phlebotomist services, medical technician services and pharmacy services, drugs or products to Patient.
c. Patient agrees that the physician performing the physical examination of Patient and supervising treatment of Patient shall not provide any urgent or emergency medical care to Patient with regard to any urgent or emergency medical condition that arises from any treatment prescribed by an independent contracting or employee physicians of American Medical. Patient go agrees to go directly to the nearest hospital emergency room in the event of any urgent or emergency medical condition arising from any American Medical treatment program or treatment adversely affecting Patient.
5.† PRIMARY CARE PHYSICIAN
a. The physician conducting the Physical Examination of Patient at the request of Patient or American Medical has agreed to provide medical supervision of the treatment prescribed by the consulting American Medical General physician. However, Patient expressly agrees to obtain or maintain their own primary care physician to provide Patient with primary medical care, including any follow-up care Patient requires that pertains to medical treatments provided Patient by American Medical.†††
b. Patient is under the care of a primary care physician, or is seeking a primary care physician, and does not consider the either the physician conducting their physical examination or the American Medical physician prescribing the medical treatment to be Patientís primary care physician.† Patient will not rely on or substitute the advice given by the examining physician or American Medical prescribing physician should it contradict the advice given to Patient by Patientís primary care physician.††
6.†††† AMERICAN MEDICAL CONDUCTS A PHYSICAL EXAMINATION AND EVALUATES PATIENTíS MEDICAL HISTORY AND MEDICAL COMPLAINT BEFORE PRESCRIBING ANY MEDICAL TREATMENT
a. Patient understands that American Medical does not anticipate any adverse effect to arise as a result of any medical program provided Patient. Patient also understands that the practice of medicine by any of its employed or contracting physicians is not an exact science and that no specific outcome from treatment can be assured Patient.
b. Patient is freely seeking Patient medical services offered by National Medical with an understanding that a local community physician will conduct the physical examination of Patient and supervise Patientís medical treatment prescribed by an American Medical physician.
c. Patient is also aware that all medical programs offered by National Medical require that an American Medical contracting or employee physician prescribe any medical program offered by American Medical.
d. Patient has examined and requested a medical program offered by American Medical and understands the nature and risks inherent in the medical program purchased from American Medical.
e. Patient represents that all information provided American Medical by Patient is complete, correct and accurately reflects Patientís known medical condition.†††
f. Patient has sought the medical program ordered from American Medical because Patient is seeking a specific prescription medication or medical treatment to treat an already-identified medical or cosmetic condition.††
g. Patient agrees not to make a claim that the American Medical prescribing physician acted unprofessionally or below the standard of care because the prescribing physician relied upon the findings of a physical examination of Patient conducted by an examining physician or the Patient medical history obtained by the examining physician.
7.†††† PATIENT INFORMATION EVALUATED BY AMERICAN MEDICAL PRESCRIBING PHYSICIAN
a. An American Medical physician shall evaluate the medical condition of Patient as evidenced by the following medical records and render the services listed below in consultation with a local physician who shall conduct a physical examination of Patient and supervise the Patientís treatment prescribed by the consulting American Medical employee or contracting physician.
b. Evaluate Patientís current physical examination report prepared by the local physician who conducted the physical examination of Patient;
c. Evaluate Patientís current medical history and medical complaint report as reported by Patient to the examining physician at the time of the physical exam;
d. Evaluate Patientís current medical condition as reported by the examining physician on American Medical’s form entitled Examining Physicianís Physical Examination Acknowledgementí;
e. Evaluate Patientís current medical condition and complaint as reported by Patient to the examining physician and provided by Patient to National Medical in the Patient completed form entitled: ĎPatient Confidential Medical History Questionnaireí;
f. Evaluate any available current medical laboratory diagnostic test report reflecting Patientís current hormone(s) level(s);
g. Consult with the examining physician to the extent medically appropriate under the circumstances;
h. Assure that there is some logical connection between the medical complaint of the Patient and any drug or medical treatment prescribed for Patient; and,
i. Issue a prescription for medical treatment and medication if medically appropriate for the Patient
8.†††††††††††† PATIENT AGREES TO PROVIDE ACCURATE AND COMPLETE INFORMATION TO EXAMINING PHYSICIAN AND TO AMERICAN MEDICAL
a. The physician conducting Patientís physical examination and the American Medical consulting physician prescribing Patientís medical treatment shall obtain Patient information, draw conclusions and make decisions based upon Patientís honest responses to questions presented Patient by the examining physician and American Medical.†† Patient represents that all responses to questions regarding Patientís medical condition shall be truthful, accurate and complete.
b. Patient understands that failure to provide truthful, accurate and complete information to the physician conducting the physical exam of Patient or to American Medical on any data collection form could cause the American Medical prescribing physician to unknowingly make an inappropriate treatment decision affecting the physical or mental health of Patient.†
a. Patient understands that American Medical does not practice medicine and functions as a medical management services organization coordinating the services and products of medical organizations.
b. Unless otherwise communicated by National Medical to Patient in writing, the physician who reviews the physical exam report and other Patient medical records; and who makes the medical determination as to whether or not to issue Patient a prescription for medication or treatment is an independent contractor of American Medical and is not an agent or employee of American Medical nor any medical organization that provides the examining physician for Patientís physical examination. National Medical does not direct, control or influence the treatment decisions made by the prescribing physician with respect to Patient care or any Patient request for specified treatment.† National Medical compensates prescribing physicians the same amount for professional services rendered regardless of whether or not a prescription is issued for treatment sought by Patient.
c. Patient understands and agrees that Patient medical records becomes the property of American Medical; and that, in addition, American Medical will have continuing access to and the right to copy and retain any and all portions of my medical records.
d. Patient understands and agrees that a duplicate copy of Patient medical records also become the property of the medical organization or physician that conducts Patientís physical examination; and that, in addition, said medical organization and examining physician shall have continuing access to and the right to copy and retain any and all portions of Patientís medical records.
10.† PATIENT REPRESENTATIONS AND ASSURANCES
a. Patient is over 18 years of age
b. Patient is not currently seeking the prescription or medical treatment sought from American Medical from Patientís primary care physician for Patientís own personal reasons or because Patientís primary physician is not familiar with the medical treatments offered by American Medical.
c. Patient agrees that any claim or action brought by Patient against American Medical, its agents, officers, directors, owners, shareholders, physicians, contractors and affiliated companies shall be brought in Palm Beach County, Florida, which is granted exclusive jurisdiction and venue of claims brought by Patient, or any assignee, against said parties, arising from any transaction or occurrence involving Patient and said parties.† Patient unconditionally and expressly waives all claims and defenses that might be brought or asserted by Patient in any such action against said parties. Patient agrees that this agreement is voluntary and that it is binding to any individual or entity claiming by or through Patient or on behalf of Patient. Patient further agrees to pay all attorneys fees and costs incurred by National Clinic as they are incurred in the event Patient brings any action or claim against American Medical in violation of this provision; or in violation of any term, condition or provision of this Agreement; or brings an action against American Medical, or any of its officers, directors, employees, agents or contractors inconsistent with Patientís waiver of all claims and defenses as set forth in this Agreement.
d. Patient is aware of potential side effects associated with medication requested by Patient and personally accepts all risks involved in taking such medication; and Patient agrees not to seek any indemnification, damages of any kind, or any other liability from American Medical, its officers, directors, employees, parent, subsidiaries, affiliates, contractors, agents, or any medical organization or pharmacy that provides Patient with medical services or products at the request of American Medical in the event Patient experiences any of the adverse side effects of prescribed medication.
e. Patient understands that American Medical, its employees, agents, contractors, employed physicians, contracting physicians, nurses, sales personnel, administrative personnel and other entities and organizations and their employees who provide medical services or products to Patient at the request of American Medical cannot guarantee that the prescription medication or treatment sought by Patient will provide the results sought by Patient.
f. Patient has obtained and consulted with Patientís primary care physician and/or pharmacist and Patient is not taking any medication or combination of medications that will make the medication requested from American Medical inadvisable to take (contraindicated); and Patient agrees to advise Patientís primary care physician of any medications obtained through American Medical before commencing use of such medication.†
g. Patient agrees that this Agreement shall serve as Patientís authorization for American Medical to release or disclose Patientís medical information to medical organizations rendering medical services to Patient at the request of American Medical. This consent does not give American Medical the right to sell Patientís name or information to any third party.
11. MISCELLANEOUS PROVISIONS
a. Patient understands that all prescription medications cannot be returned to the dispensing pharmacy, American Medical or any other individual or entity after the medication has been dispensed to Patient.
b. It is agreed and understood that National Medical shall refund 100% of purchased funds if a prescription is not issued for the treatment sought by Patient after Patient has completed the required physical exam, completed any required blood test and assured that National Medical has received the above referenced three physical exam reports.
d. This Agreement represents the complete and entire agreement between the parties to it.† No prior written or electronic agreement, verbal communication or verbal agreement may be offered or used to alter any terms or condition of this Agreement; nor shall such extrinsic agreements be effective or binding between the parties regarding any term or condition of this Agreement or be offered or introduced to show intent of a party to any matter pertaining to this Agreement.
e. I, the Patient, including the purchaser if different from Patient, agree in good faith that Patient shall provide AMG with the following accurate, truthful representations: accurate, truthful representations about the current medical condition of Patient; accurate, truthful representations in the full disclosure of all material facts about the current Patient medical history and symptoms; and, accurate, truthful representations re Patient current Patient medications and treatments. Patient agrees in good faith to undergo and completed the following AMG requests or instructions with regard to this purchased assessment for treatment and indicated medical treatment: Complete AMG requested Patient lab tests; undergo the Patient physical examination and evaluation by the AMG treating medical provider at the time and date scheduled; comply in good faith within the time periods specified with AMG procedures and policies for providing my complete and accurate medical history to AMG and the AMG treating medical provider; provide AMG requested blood specimens, and respond to all AMG communications so that I may obtain the medical treatment purchased if it is indicated. In the event I fail to comply with any term or condition of this agreement, and thereby inhibit the effort of AMG to perform its contract with me, which is to obtain my current medical history, provide me with laboratory blood testing, provide me with a physical examination and evaluation by the medical provider who proscribes me the purchased medical treatment if my evaluation indicates that the treatment is appropriate for my medical condition; and to assure that a pharmacy dispenses any prescribed medications for such treatment to me. I expressly instruct AMG to charge my credit card with liquidated damages in the form of the sum of the following cancellations fees if I do any of the following cancel any aspect of my AMG defined assessment process for this medical treatment; fail to take any AMG required medical laboratory test; fail to complete any AMG scheduled physical examination of me by a medical provider; or in the event I cancel this treatment purchase. I agree that my cancellation fees shall include the following; a minimum or transactions cancellation fee of $1500.00 charged by AMG for processing any patient cancellation of enrollment in medical treatment; plus an amount equal to all AMG fees charged me for all AMG administrative services including preparation of my medical file for the AMG selected medical provider,; plus an amount charged by AMG for medical laboratory testing purchase by AMG for me; plus the fee charged by AMG for any physician or pharmacy services rendered to me with regard to my enrollment in treatment, plus the fee charged by AMG for an independent pharmacy to dispense prescribed medications directly to me pertaining to my purchased medical treatment. The sum of these cancellation fees constitute liquidated damages as the agreed estimated damages sustained by AMG in its unsuccessful attempt to provide me services as a result of my failure to complete the treatment assessment process ad defined by AMG and the medical provider to whom AMG refers me or my cancellation of enrollment and purchase of a medical treatment. These damages are specified because it is difficult to ascertain actual financial damages arising from my failure to comply with this provision or my cancellation of a medical treatment purchased from American Medical General, Inc. Any of my AMG treatment purchase fee remaining after deducting the total sum amount of all the my above identified cancellation fees is the amount to be refunded to me in the event I cancel my purchase of this medical treatment of fail to comply with any term of this agreement.
f. Subject to all of †the above terms and conditions of this agreement and paragraph 11. e., AMG shall not charge Patient the price of a medical program if the AMG physician declines to issue a prescription for the purchased program, so long as, Patient has fully cooperated in good faith with the requests, procedures and policies of American Medical General, Inc.
g. ALL INFORMATION, ITEMS, MEDICAL PROGRAMS, AND SERVICES CONTAINED ON THIS WEB SITE ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EXPRESSED OR IMPLIED.†††
h. IN USING THIS WEB SITE, PATIENT UNDERSTANDS AND AGREES; (A) THAT AMERICAN MEDICAL AND ITS CONTRACTORS ARE NOT RESPONSIBLE FOR THE NEGLIGENT OR INTENTIONAL ACTS OR OMISSIONS OF ANY HEALTH CARE PROVIDER OR SUPPLIER THAT PATIENT OR SITE VISITOR MAY BE LINKED WITH OR FOR ANY ACTION OR INACTION TAKEN BY SITE VISITOR OR PATIENT IN RELIANCE UPON THE INFORMATION COMMUNICATED TO SITE VISITOR OR PATIENT VIA THIS WEB SITE; (B) THAT THE TOTAL LIABILITY OF AMERICAN MEDICAL, ITS CONTRACTORS, ORGANIZATIONS PROVIDING PHYSICIANS AND ITS AFFILIATES, IF ANY, ARISING FROM OR RELATED TO INTERACTIONS PATIENT HAS WITH OR THROUGH THIS WEB SITE (WHETHER THE CLAIM IS CONTRACT, TORT, WARRANTY, NEGLIGENCE, MALPRACTICE, FRAUD, OR OTHERWISE) IS LIMITED TO THE PURCHASE PRICE OF ANY PRODUCTS IN ANY RELEVANT TRANSACTION AND (C) THAT NATIONAL MEDICAL, ITS CONTRACTORS, ORGANIZATIONS PROVIDING PHYSICIANS AND ITS AFFILIATES SHALL NOT BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL, OR PUNITIVE DAMAGES.† IN ACCORDANCE WITH THE ABOVE UNDERSTANDING, PATIENT AGREES TO RELEASE AMERICAN MEDICAL GENERAL, INC. ITS EMPLOYEES, AGENTS, CORPORATE AFFILIATES, CONTRACTORS, EXAMINING PHYSICIANS, PRESCRIBING PHYSICIANS, AND RELATED PARTIES FROM ANY AND ALL LIABILITY ASSOCIATED WITH OR ARISING FROM ANY PHYSICIAN SERVICES RENDERED, ANY PRESCRIPTION DRUGS DISPENSED OR FROM THE MEDICAL, PHYSICAL, BEHAVIORAL OR OTHER EFFECTS OF ANY MEDICATION THAT MAY BE ORDERED, PRESCRIBED OR PURCHASED AS A RESULT OF A PRESCRIBED MEDICATION OR TREATMENT OBTAINED THROUGH AMERICAN MEDICAL.†
i. IF ANY PROVISION OF THIS AGREEMENT IS HELD TO BE VOID, UNENFORCEABLE OR ILLEGAL, THEN PATIENT AND AMERICAN MEDICAL AGREE THAT THE AGREEMENT WILL BE CHANGED OR LIMITED ONLY TO THE EXTENT NECESSARY TO ENABLE THE REMAINING PROVISIONS TO BE OF FULL FORCE AND EFFECT.
j. i†††††† Patient understands, accepts and agrees that payment for physician service fees, laboratory service fees and the cost of prescription drugs dispensed and shipped to Patient shall not be refunded to Patient after the services are rendered or prescription drug has been shipped to Patient.† If the Patient fails to receive a prescription drug shipment, then the pharmacy agrees to promptly send a replacement prescription shipment to Patient at pharmacyís sole expense.
k. Patient agrees that a delivery receipt for a shipment from National Clinic, its contractors, any independent pharmacy, or any delivery service signed by a person at the Patientís shipping address shall constitute conclusive evidence of the delivery and receipt of the prescription drug and full performance of the obligations of American Medical to Patient. Patient irrevocably agrees and instructs Visa, MasterCard, or other credit card provider or processor, and Patientís bank to withdraw any asserted credit card dispute submitted by provided any independent evidence of delivery of the shipment to Patientís address can be produced by American Medical. Federal Express or other delivery services reported delivery to the Patientís shipping address on the Federal Express or delivery serviceís website shall constitute delivery to Patient. Federal Expressís reported delivery to the Patientís shipping address on the Federal Express website with a reported wavier of signature on file with Federal Express for deliveries to Patientís shipping address, shall also constitute delivery of the prescription drug and its receipt by Patient. The reported delivery of the prescription medicine shipment by the United States Postal Service to the Patientís address on its website shall also constitute delivery to Patient and conclusive evidence of the full performance of this Agreement by American Medical. American Medical shall use its best efforts in good faith to assure a high level of service to Patient, including the timely delivery of all prescription medicine dispensed by the responsible pharmacy.
l. In consideration of any clinic, physician, laboratory services provided purchaser (Patient) by AMG, purchaser (Patient) expressly and irrevocably waives any right to file any type of credit card dispute with regard to any AMG purchase transaction after purchaserís receipt of any of the foregoing services. Therefore, purchaser (Patient) irrevocably agrees and instructs American Medical General, Inc. (hereafter ďAMGĒ) to charge the same credit card provided to AMG by purchaser (Patient) for the payment of the purchase price of the current medical program ordered by purchaser form AMG an amount equal to $500.00 for each occasion that an employee or staff member of AMG expends time responding to a credit card dispute or preparing documentation initiated by purchaser following purchaserís receipt of any AMG provided clinic, physician or laboratory services. Further, the filing of such a dispute after receipt of any clinic, laboratory or physician services provided at the expense of AMG is an admitted material breach of this agreement by purchaser entitling AMG to an undisputed summary judgment for liquidated damages in the amount of $20,000.00 and reasonable attorneyís fees and costs incurred in enforcing this agreement.Ē The purchaser (Patient) is not entitled to a refund of any portion of the purchase price paid to AMG for a medical program after any clinic, physician or medial laboratory services have been provided to purchaser (Patient) at the expense of AMG.Ē If purchaser (Patient) files any documents opposing the motion for summary judgment, then the amount of the Summary Judgment to be awarded AMG shall increase by an additional $20,000.00. Purchaser waives all claims and defenses in regard to this transaction and any action brought against purchaser by AMG arising from this transaction. In the event of any dispute, the fees contained in the written confirmation of order provided patient at the time of sale and the entries of services on the order events log shall be deem conclusive as to the enrollment program price to be charged patient and services that have been provided patient in connection with the purchaserís order. Jurisdiction and venue for any claim arising from this transaction shall be Palm Beach County, Florida.
13.†††††††††† PATIENT WAIVER OF CLAIMS AND DEFENSES
PATIENT UNCONDITIONALLY AND EXPRESSLY WAIVES ANY AND ALL CLAIMS AND DEFENSES AGAINST AMERICAN MEDICAL, ITS SHAREHOLDERS, DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, CONTRACTING PHYSICIANS, AND ANY AND ALL ORGANIZATIONS AND THEIR EMPLOYEES PROVIDING SERVICES OR PRODUCTS TO PATIENT ON BEHALF OF AMERICAN MEDICAL FOR ANY CLAIM RELATING DIRECTLY OR INDIRECTLY TO ANY SERVICE OR PRODUCT PURCHASED BY PATIENT FROM AMERICAN MEDICAL. THIS WAIVER INCLUDES, BUT IS NOT LIMITED TO, ANY ILLNESS, BODILY INJURY OR OTHER ADVERSE PHYSICAL, MENTAL OR MEDICAL CONDITION SUSTAINED BY PATIENT AS A RESULT OF A SERVICE OR PRODUCT PURCHASED FROM AMERICAN MEDICAL BY PATIENT OR PROVIDED TO PATIENT BY ANY MEDICAL ORGANIZATION OR CONTRACTING PHYSICIAN OF AMERICAN MEDICAL. PATIENT EXPRESSLY WAIVES ANY AND ALL DEFENSES IN ANY ACTION BROUGHT BY PATIENT AGAINST NATIONAL OR ANY OF ITS CONTRACTORS. PATIENT UNDERSTANDS THE NATURE OF THIS WAIVER OF CLAIMS AND DEFENSES AND VOLUNTARILY AGREES TO THIS WAIVER OF CLAIMS AND DEFENSES.†† THIS WAIVER OF CLAIMS AND DEFENSES IS BINDING TO ANY INDIVIDUAL OR ENTITY CLAIMING BY, OR THROUGH, OR ON BEHALF OF PATIENT. PATIENT HOLDS AMERICAN MEDICAL, ITS AGENTS, SHAREHOLDERS, DIRECTORS, OFFICERS, EMPLOYEES AND CONTRACTORS. PATIENT HOLDS EACH HARMLESS AND INDEMNIFIES EACH FOR ANY LIABILITY ARISING IN CONNECTION WITH THE TREATMENT PROGRAM PURCHASED FROM AMERICAN MEDICAL BY PATIENT
14.†††††††††† PATIENT WAIVER OF ALL CLAIMS AND DEFENSES INCLUDES ANY CLAIM OR DEFENSE THAT COULD OTHERWISE BE ASSERTED AGAINST ANY MEDICAL ORGANIZATION WHICH PROVIDES PATIENT MEDICAL SERVICES, CONDUCTS PATIENTíS PHYSICAL EXAM, DISPENSES MEDICATION TO PATIENT OR SUPERVISES PATIENTSí MEDICAL TREATMENT AT THE REQUEST OF AMERICAN MEDICAL
PATIENT UNCONDITIONALLY AND EXPRESSLY WAIVES ANY AND ALL CLAIMS AND DEFENSES AGAINST ANY MEDICAL ORGANIZATION, OR INDIVIDUAL THAT PROVIDES PATIENT WITH SERVICES OR PRODUCTS AT THE REQUEST OF, OR ON BEHALF OF, AMERICAN MEDICAL. THIS WAIVER OF ALL CLAIMS AND DEFENSE INCLUDES THOSE AGAINST ANY MEDICAL ORGANIZATION, ITS AGENTS, DIRECTORS, OFFICERS AND EMPLOYEES, AND CONTRACTORS IF SUCH ORGANIZATION EMPLOYS THE PHYSICIAN WHO CONDUCTS THE PHYSICAL EXAMINATION OF PATIENT OR EMPLOYS ANY PHYSICIAN WHO SUPERVISES A MEDICAL TREATMENT PRESCRIBED PATIENT BY AN EMPLOYEE PHYSICIAN OR CONTRACTING PHYSICIAN OF AMERICAN MEDICAL.† THIS WAIVER EXPRESSLY INCLUDES THE MEDICAL ORGANIZATION WHICH EMPLOYEES THE PHYSICIAN WHO CONDUCTS THE PHYSICAL EXAMINATION OF PATIENT, THE INDIVIDUAL PHYSICIAN WHO CONDUCTS THE PHYSICAL EXAMINATION OF PATIENT ANDTHE PHYSICIAN WHO HAS THE RESPONSIBILITY FOR SUPERVISING THE MEDICAL TREATMENT PRESCRIBED FOR PATIENT BY A CONTRACTING OR EMPLOYEE PHYSICIAN OF AMERICAN MEDICAL.† THIS WAIVER INCLUDES, BUT IS NOT LIMITED TO, CLAIMS RELATING TO ANY ILLNESS, BODILY INJURY OR OTHER ADVERSE PHYSICAL, MENTAL OR MEDICAL CONDITION SUSTAINED BY PATIENT AS A RESULT OF MEDICAL SERVICES OR PRODUCTS PURCHASED FROM AMERICAN MEDICAL BY PATIENT. THIS WAIVER ALSO INCLUDES ANY CLAIM AGAINST ANY MEDICAL LABORATORY, PHARMACY AND PHYSICIAN CONTRACTING WITH AMERICAN MEDICAL, WHICH PROVIDES SERVICES OR PRODUCTS TO PATIENT.† PATIENT UNDERSTANDS THE NATURE OF THE WAIVER OF CLAIMS AND DEFENSES AND VOLUNTARILY AGREES TO THESE WAIVERS.† THIS WAIVER OF CLAIMS AND DEFENSES IS BINDING TO ANY INDIVIDUAL OR ENTITY CLAIMING BY OR THROUGH OR ON BEHALF OF PATIENT.†
15.†††††††††† PATIENT AGREEMENT AND ELECTRONIC SIGNATURE VALID AS ORIGINAL SIGNATURE FOR PURPOSES OF ENFORCEABILITY OF THIS AGREEMENT
Patient evidences understanding and acceptance of this Agreement by indicating agreement to its terms when the question of acceptance is presented on a National Clinic website. Patient may also be request to fax American Medical a signed copy of this printed Agreement in some circumstances. However, a signed printed Agreement is not necessary for this Agreement to binding on the Patient and American Medical General, Inc.
American Medical manifests its acceptance of this Agreement by receiving this order submitted online by Patient.
The purchaser and American Medical General, Inc., parties to this Agreement, understand and agree to accept all of the terms, conditions and provisions of thisí Waiver of Claims and Informed Consentí †on the date the order is submitted to American Medical General by Patient or employee or agent of American Medical General, Inc. at the request of Patient.† It shall
be deemed a conclusive fact and presumption that the employee or agent of American Medical General, Inc. was
specifically authorized by the purchaser and Patient to enter this order on behalf of purchaser and Patient, including the
electronic signatures of purchaser and Patient if the data entered in connection with this transaction includes personal
information of purchaser and Patient of the type that would not be know by the agent or employee of American Medical General, Inc., including, but not limited to any one of the following: purchaser or Patientís social security number, date of birth, phone number or address.
The submission of a purchase order by yourself or an employee of American Medical General, Inc. constitutes your electronic signature and
agreement to all terms and conditions of this agreement.
The submission of a purchase order by yourself or an employee of American Medical General, Inc. constitutes your electronic signature and agreement to all terms and conditions of this agreement.