Medical Release of Liability Form
Please read this form carefully before signing.
DESCRIPTION OF MEDICAL ACTIVITY
This release pertains to the following medical treatment, procedure, or activity:
RELEASE OF LIABILITY
I, the undersigned Releasor, hereby release, waive, discharge, and hold harmless the Releasee, its agents, employees, officers, directors, and affiliates from any and all claims, demands, causes of action, damages, or liability of any kind arising from or in connection with the medical treatment or procedure described above.
ASSUMPTION OF RISKS
I acknowledge and understand that medical treatments and procedures may involve inherent risks, dangers, and complications, which could result in injury, illness, or even death. These risks may include, but are not limited to:
Adverse reactions to medication or anesthesia
Infection
Complications during or after surgery or treatment
Injury from equipment or instruments
I voluntarily assume all risks associated with the medical treatment or procedure, whether or not the risks are listed above.
MEDICAL AUTHORIZATION
In the event of an emergency, I hereby authorize the Releasee or its designated agents to seek necessary medical treatment on my behalf should I be unable to make decisions regarding my own care. I understand that I will be responsible for any medical costs incurred as a result of such treatment.
NO ADMISSION OF LIABILITY
This release does not constitute an admission of liability or fault by the Releasee. It is simply a waiver of liability in the event of complications, accidents, or injuries arising from the medical treatment or procedure.
ENTIRE AGREEMENT
This document represents the complete and entire agreement between the parties regarding the release of liability for the medical treatment or procedure and supersedes any prior agreements or understandings.
Releasor Signature:
Name:
Date:
Releasee Signature:
Name:
Date:
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