Life and Soul: Patient Registration
Timing: September 14, 2019. 8 am to 12 pm
Address: 3945 CR 58, Manvel, Texas
Contact us at 281-402-6585 or
Consent and Release Statement
I agree and request that health checks be performed for me by all persons administering, supervising or evaluating any test, including but not limited to medical practitioners, physicians, nurses, pharmacists, medical assistants, volunteers, etc. participating in the Love to Share Foundation America (“LTSFA”) Health Fair.
I understand that:
1. All health checks will be performed without charge to me unless otherwise stated
2. The data derived from the Health checks / tests / screens is to be considered preliminary and not conclusive
3. I (not the participating organizations) am responsible for initiating any follow-up examinations for abnormalities identified at the Health Fair
4. Not all the tests / screens will be conducted by nurses and doctors
5. The tests / screens provided to me are not comprehensive and should not take the place of regularly scheduled medical examinations. If there are specific medical complaints on my part, I should consult my personal physician regardless of the health check results
6. LTSFA or other participants or sponsors will NOT be retaining / keeping any of my medical records and I will be given all the original results of the screenings / tests done
7. LTSFA may use photographs/videos of me taken during the health fair with or without my name and for any lawful purpose, including for example such purposes as, but not limited to, publicity, illustration, advertising, and web content.
I have read and understand the above paragraphs and I HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO file any legal claim/sue Love to Share Foundation America conducting the health fair, its event committee, officers, directors, members, volunteers, employees, agents, sponsors, other participants, operators, officials, advertisers, owners and each of them, their officers and employees, all for the purposes herein referred to as "releasees", from all liability to me, my personal representatives, assigns, heirs, and next of kin for any and all loss or damage, and any claim or demands therefore on account of injury to me or any eventualities and inaccuracies in test results, anything committed or omitted by releasees which may arise, and/or from any distributed information, and/or educational services performed at the Health Fair, whether caused by the negligence of the releasees or otherwise.
I further expressly agree that the foregoing release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted, that if any portion thereof is held invalid, it is agreed that the remaining shall, notwithstanding, continue in full legal force and effect.
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