WaversWithAdvice

sansa

ACKNOWLEDGEMENT AND CONSENT FORM

I hereby represent and acknowledge that USAppointment will assist me, free of charge, with the process of scheduling a medical oncology appointment abroad. USAppointment will: (i) assist me with the documents to be presented; (ii) indicate a company that will translate clinical reports and other documents to be delivered to the foreign physician,  schedule a medical appointment abroad on my behalf and assist me in the choice of lodging in the country where I will be examined. I also acknowledge that USAppointment will not provide any type of medical assistance, nor has it any influence on or responsibility for the medical advice that I will receive abroad. Accordingly, I cannot claim or demand any responsibilities in this respect from USAppointment. I also represent that I am aware that all costs and expenses in connection with my medical appointment with the foreign professional, including medical fees, translation, lodging, transportation, and meal expenses, among others, are fully and exclusively payable by me. These expenses will not be paid to or by USAppointment. I acknowledge that I am responsible for paying these costs directly to the professionals and/or institutions that provide the relevant services.

Patient:
ID (RG):*
CPF:*

If patient is under 18 years of age, parent or guardian must sign.

Signee Name:
Relation to Patient:
ID (RG):
CPF:

Agree


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