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INTERNATIONAL HEALTH CARE PROVIDERS, INC. ("IHP")
INTERNATIONAL PATIENT INTAKE FORM, AGREEMENT, ACKNOWLEDGEMENT
AND WAIVER
Date: / Date of Birth: (DD/MM/YYYY)Full Name: / (the "Customer")
Address:
Home No.: / Mobile No.:
Email:
Do you have US health Coverage? / Yes / No / Do you have secondary health coverage? / Yes / No
Emergency Contact Name:
Relationship: / Phone No.:
How did you hear about IHP?
What services and/or procedures are you requesting?
Family Physician: / Contact details:
Do you have copies of your most recent medical records? / Yes / No
Do you take prescription medication? / Yes / No / If YES, list all medications:
______
______
______
______
Patient Allergies:
Additional Patient Conditions:
Are you a Canadian Citizen? / Yes / No / If NO, what is your citizenship?
Do you have the appropriate documents to enter the USA? / Yes / No / Do you have travel insurance? / Yes / No
Method of Payment: / Cash / Credit Card / Certified Cheque
TERMS AND CONDITIONS
WHEREAS the Customer wishes to retain International Health Care Providers, Inc. ("IHP)" as a consultant to assist the Customer in procuring for the Customer such healthcare services or medical treatments from doctors, clinics and healthcare providers (collectively, "Medical Centres", and individually, the "Medical Centre") as may be available and agreed upon by the Customer (the "Medical Treatment") (such consulting service rendered by IHP hereunder are hereinafter referred to as the "Consulting Services").
NOW THEREFORE in consideration of IHP providing the Consulting Services to the Customer and other good and valuable consideration, the receipt and sufficiency of which consideration is hereby acknowledged, the Customer agrees with IHP as follows:
1. Retainer of IHP: The Customer hereby retains IHP to provide such Consulting Services to the Customer as the Customer and IHP may agree upon.
2. IHP Not a Healthcare Provider: The Customer acknowledges, understands and agrees that IHP does not, directly or indirectly, in any manner or by any means, deliver, perform, regulate, control or otherwise provide the Medical Treatment or healthcare or medical services of any nature or kind. The Customer acknowledges, understands and agrees that the decision to proceed with the Medical Treatment is the Customer's alone.
3. IHP Does Not Guarantee Outcomes: The Customer hereby acknowledges, understands and agrees that IHP has not made any promises or guarantees as to the benefits, outcomes or success of the Medical Treatment or whether the Medical Treatment will cure the Customer, prolong the Customer's life, improve the Customer's quality of life, ease the Customer's suffering, prevent future disease or suffering or otherwise be effective. The Customer acknowledges, understands and agrees that IHP is not responsible for any failures in the Medical Treatment or any loss, damage, complication or injury suffered by or occasioned to the Customer, including consequential damages, result from or associated with the Medical Treatment, the Medical Centre, the Consulting Services or this agreement.
4. Personal and Health Information: The Customer hereby consents to the collection, use and disclosure of the personal and health information and records of the Customer by IHP for the purpose of facilitating any of the Consulting Services or communicating with Medical Centres with respect to the Medical Treatment. The Customer acknowledges, understands, and agrees that Medical Centre providing the Medical Treatment may require additional personal and health information and legal waivers, indemnities and other documentation in order to admit the Customer for Medical Treatment and carry out the Medical Treatment and for related healthcare services, and the Customer bears sole responsibility to comply with these requirements.
5. Payment of Fees: At such time as IHP is able to procure the Medical Treatment on behalf of the Customer, the Customer agrees to remit to IHP the amount of the fees payable to the Medical Centre for the Medical Treatment (the "Medical Treatment Fee") together with the agreed upon consulting fees owing by the Customer to IHP for the Consulting Services (the "Consulting Fee") and in any event such fees shall be paid by the Customer to IHP not less than 15 business days prior to the scheduled Medical Treatment. Upon receipt of payment for the Medical Treatment Fee and the Consulting Fee, IHP shall transmit the Medical Treatment Fee to the Medical Centre. IHP shall be entitled to retain the Consulting Fee on a non-refundable basis, regardless if Customer receives the scheduled Medical Treatment or any medical or healthcare services whatsoever.
6. Additional Expenses: Any and all expenses, costs and fees related to or associated with the Medical Treatment not included in the Medical Treatment Fee, including travel to and from the Medical Centre and lodging in proximity to the Medical Centre, shall be for the sole account of and be paid for by the Customer at the time such expenses arise, and in no event shall IHP be liable for any such expenses, costs, and fees.
7. Consulting Fees from Healthcare Providers: The Customer acknowledges that IHP has entered into legal agreements with certain healthcare providers to act as their representative in Canada to source and screen individuals in Canada who have healthcare needs that are not being met and connecting such individuals to Medical Centres for treatment. IHP HEREBY DISCLOSES TO THE CUSTOMER THAT IHP RECEIVES ON GOING CONSULTING FEES FROM SOME MEDICAL CENTRES, WHICH FEES ARE IN ADDITION TO THE CONSULTING FEE PAID OR OWING TO IHP BY THE CUSTOMER.
8. Indemnity: To the full extent permitted by law, the Customer agrees to indemnify, defend and save harmless IHP and the officers, directors, employees, owners, agents and successors and assigns of IHP (collectively referred to in this section as "IHP etal"), of, for and against any and all actions, manner of actions, causes of actions, suits, demands, fines, penalties, claims and liabilities of every nature, kind and description whatsoever and howsoever arising that IHP etal may suffer or incur, directly or indirectly, at any time and in any manner relating to or associated with the Medical Treatment, the Medical Centres or the Consulting Services.
9. Acknowledgement and Warning Travel Documentation: The Customer acknowledges that Canadian citizens travelling to any destination outside of Canada may be required to present a valid Canadian passport, which must be valid for at least six months past the Customer's return date. Since some countries require a visa for transit or entry, it is the Customer agrees that it is the Customer's sole responsibility to ensure that they have all the proper documents for entry. All names on documents must match the legal name on the Customer's photo identification presented to IHP, and travel document information must match tickets. Please check the Canadian Government website at http://travel.gc.ca/ for further information. Failure to comply with these regulations may result in denied boarding, denied entry and/or government imposed fines. If you are a citizen of another country, there may be additional requirements. Check with the nearest consulate or embassy of the destination you are travelling to and find out the entry requirements for non-Canadian citizens.
10. Severability: In the event any provision of this agreement, or part thereof, shall be found to be void or invalid by a court of competent jurisdiction, such void or invalid provision, or part thereof, shall be deemed to be severed from this agreement without in any way affecting the validity, enforceability or effect of any of the remaining provisions, or parts hereof, which shall remain in full force and effect.
11. No Waiver: No supplement, modification or amendment of this agreement shall be binding unless executed in writing by IHP and the Customer. No waiver of any of the provisions of this agreement shall be deemed or shall constitute a waiver of any other provision hereof (whether or not similar) nor shall such waiver constitute a continuing waiver.
12. Enurement: The provisions of this agreement shall enure to the benefit of IHP and the Customer, and shall be binding upon the heirs, successors, assigns and legal representatives of IHP and the Customer.
13. Jurisdiction: This agreement shall be governed by and construed in accordance with the laws of the Province of Ontario and the federal laws of Canada applicable therein, without regard to choice of law rules. The Customer hereby irrevocably attorns to the jurisdiction of the Courts of the Province of Ontario, for determination of all matters arising under or in connection with this Acknowledgement and Waiver.
14. Acknowledgment: THE CUSTOMER HEREBY REPRESENTS AND DECLARES THAT THE CUSTOMER:
(a) HAS CONSULTED WITH A LAWYER CONCERNING THIS AGREEMENT, ITS PURPOSE AND LEGAL EFFECT, OR
(b) WAS PROVIDED WITH THE OPPORTUNITY TO CONSULT WITH, AND HAD THE ABILITY AND MEANS TO CONSULT WITH, A LAWYER CONCERNING THIS AGREEMENT, ITS PURPOSE AND LEGAL EFFECT, BUT MADE A VOLUNTARY AND INFORMED DECISION NOT TO DO SO.
IN WITNESS WHEREOF the Customer has executed this acknowledgement and waiver effective as of the date first above written.
______WITNESS TO THE SIGNATURE OF THE CUSTOMER / ______
SIGNATURE OF THE CUSTOMER
______
NAME OF THE WITNESS
______
ADDRESS OF THE WITNESS
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