AMA Doctor Client Contract
Full Legal Name of Client *
Client Phone Number *
Client Mailing Address *
What is your height *
What is your current weight *
Do you have any health issues currently. Please list them *
Have you ever had surgery. Please detail *
AMA Doctor Name
AMA Doctor Email *
AMA Doctor Phone Number *
What issues does the client have with their health (LIST ALL with dates of diagnosis) *
What are the current major health concerns you have as a client. Describe how you are feeling in detail *
Services of Doctor-Check Boxes that apply (Consultation or Bioscan will always apply) *
Required
Advanced Healing Service-Tribal Members Only *
Required
CONTRACT TERMS - This contract is between the parties (Client & Indigenous Doctor). Doctor agrees to perform the service as described. Client agrees to fulfill signing this contract and agrees to provide all info necessary to Doctor to complete services. In any event of a dispute client agrees to arbitration or trial via the ARNA Jural Society to resolve the matter. Doctor agrees to render service in a timely fashion as expected by AMA (Aboriginal Medical Association) policy and or agreement with the client. Do you agree to the terms of service as Client *
SIGNATURE- By Signing this contract electronically i agree to the terms and reserve my right to arbitration or trial in any matters of controversy. Type your lawful-legal name which stands as your electronic signature* CLIENT SIGNATURE  *
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