PATIENT WAIVER OF CLAIMS AND
INFORMED CONSENT AGREEMENT
AMERICAN MEDICAL GENERAL, INC. AND
American
Medical General, Inc. (hereafter “American Medical” or “AMG”) and the individual who purchases a medical treatment
from AMG or paid for the treatment of another by AMG (hereafter “Patient”) enter into this ‘Patient
Waiver of Claims and Informed Consent Agreement’ (hereafter “Agreement”) 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 Patient’s 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 Patient’s
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 Patient’s 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.
j.
An independent
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 Patient’s 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 Patient’s primary
care physician.
6. AMERICAN MEDICAL CONDUCTS A PHYSICAL
EXAMINATION AND EVALUATES PATIENT’S 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 Patient’s 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 Patient’s 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 Patient’s treatment prescribed by the
consulting American Medical employee or contracting physician.
b.
Evaluate Patient’s current physical examination report prepared by the
local physician who conducted the physical examination of Patient;
c.
Evaluate Patient’s current medical history and medical complaint report
as reported by Patient to the examining physician at the time of the physical
exam;
d.
Evaluate Patient’s current medical condition as reported by the
examining physician on American Medical’s form entitled Examining Physician’s
Physical Examination Acknowledgement’;
e.
Evaluate Patient’s 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: ‘Patient Confidential
Medical History Questionnaire’;
f.
Evaluate any available current medical laboratory diagnostic test
report reflecting Patient’s 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 Patient’s physical
examination and the American Medical consulting physician prescribing Patient’s
medical treatment shall obtain Patient information, draw conclusions and make
decisions based upon Patient’s honest responses to questions presented Patient
by the examining physician and American Medical. Patient represents that all responses to
questions regarding Patient’s 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 Patient’s 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 Patient’s 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 Patient’s 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 Patient’s
primary care physician for Patient’s own personal reasons or because Patient’s
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 Patient’s 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 Patient’s
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 Patient’s 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 Patient’s authorization for American Medical to release or disclose Patient’s
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 Patient’s 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.
c.
Patient’s electronic signature to this
Agreement shall be evidenced by Patient’s indication of the acceptance of this
Agreement while online at a website owned or controlled by American Medical. Patient
agrees that the submission of an order or a purchase of a medical program
online at a website owned or controlled by American Medical shall conclusively
evidence Patient’s understanding, acceptance and agreement to all terms and
conditions of this Agreement. One such website is
www.nationalmedicalclinic.com. However, this Agreement must be accessible for
viewing and acceptance by a Patient at the website for the submission of an
order via the website to be conclusively deemed to constitute the electronic
signature of Patient to this Agreement. Any record in the website database
reflecting Patient’s acceptance of this Agreement shall also be deemed to
conclusively establish that Patient provided an electronic signature for this
Agreement. Moreover, Patient understands and unconditionally agrees that an
order to purchase a medical program from American Medical cannot be submitted
without Patient’s understanding and acceptance of all terms and conditions of
this Agreement.
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 undergo
an AMG local physical examination; deliver the physician’s signed and completed
AMG Physical Exam Form to AMG corporate offices; provide an AMG requested
saliva or blood specimen to the identified medical laboratory; provide a
complete and truthful medical history fo AMG and its physicians; and comply in
good faith within the time periods specified with AMG procedures and policies
for obtaining my medical history,
providing saliva or blood specimens, and respond to all AMG
communications so that I may obtain the medical treatment purchased. In the event I fail to comply with any term
or condition of this provision, and thereby inhibit the effort of AMG to
perform its contract with me, which is to undertake to obtain the issuance of
my requested prescription by a physician, then I expressly instruct AMG to
charge my credit card with $900.00 as liquidated damages as the agreed
estimated damages sustained by AMG in its unsuccessful attempt to provide me
services. These damages are specified because it is difficult to ascertain
actual financial damages arising from my failure to comply with this provision
or my failure to cooperate after purchasing a medical program. In such an
event, I specifically waive any claim that said amount should not have been
charged to my credit card; any right to dispute such charge to my credit card;
and any and all defenses to such a claim. This provision shall prevail over any
credit card holder agreement that I have entered into with the credit card
issuer or issuing bank. I agree to pay any and all attorneys fees and costs
incurred by AMG in the enforcement of this provision or 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 pharmacy’s 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 Patient’s 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 Patient’s bank to withdraw any asserted credit card
dispute submitted by provided any independent evidence of delivery of the
shipment to Patient’s address can be produced by American Medical. Federal
Express or other delivery services reported delivery to the Patient’s shipping
address on the Federal Express or delivery service’s website shall constitute delivery
to Patient. Federal Express’s reported delivery to the Patient’s shipping
address on the Federal Express website with a reported wavier of signature on
file with Federal Express for deliveries to Patient’s 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 Patient’s
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 purchaser’s receipt of any of the foregoing services. Therefore, purchaser (Patient) irrevocably agrees and instructs American Medical General, Inc. (hereafter “AMG”) 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 purchaser’s 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 attorney’s fees and costs incurred in enforcing this agreement.” 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.” 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 purchaser’s 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 PATIENT’S
PHYSICAL EXAM, DISPENSES MEDICATION TO PATIENT OR SUPERVISES PATIENTS’ 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 this’ Waiver of Claims
and Informed Consent’ 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 Patient’s social security number, date of birth, phone
number or address.
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