PATIENT’S CONCENT

I, the undersigned, hereby declare, as follows:
I have contacted PRAIUM Medical Solutions for diagnosis, consultation and treatment of my own volition.
I hereby declare and confirm that I have carefully read the above "PATIENT INFORMATION" and the below "PATIENT CONSENT" forms in their entirety. My signature below constitutes my approval and consent to all of them.
I am aware that my said approval and consent are a prerequisite to the consent of PRAIUM Medical Solutions in general and Dr. Oren Kaholi and the clinic staff in particular, to provide me with a diagnosis, consultation, treatment and any other service rendered by them.
I understand that the goal of PRAIUM Medial Solutions diagnosis and treatment plan is to improve my health and help me maintain a healthier lifestyle. Therefore, in order to maximize the beneficial results as much as possible, it is my exclusive responsibility to take care and arrive to all the scheduled treatment sessions. It is also my exclusive responsibility to adhere to PRAIUM Medial Solutions medical staff advice and instructions concerning the uptake of the formulas and usage of the other products provided by the clinic, nutritional and lifestyle changes and all that is advised for reaching the goals of the treatment. PRAIUM Medial Solutions has vast experience in reaching successful results. Therefore, not adhering fully to the treatment plan might reduce the chances of success. I am also aware that not following the said treatment plan, instructions and advice might result in stopping the treatment altogether by a decision of the medical staff.
I hereby declare and confirm that the entire information disclosed by me in the PRAIUM Medical Solutions questionnaire in particular, as well as any other information provided by me in writing and orally to Dr. Kaholi and PRAIUM Medical Solutions staff in general, is the correct, precise and complete information concerning my state of physical and mental health, nutrition and lifestyle, including also: any symptoms I have, hospitalizations, surgeries, medical procedures, medication, past and present diagnosed pathologies, past and present psychiatric diagnosis, past and present addictions, present pregnancy and any other information that according to a reasonable consideration has the potential to influence the accuracy of the diagnosis and the efficiency of the treatment and its results.
I am committed to update and notify immediately PRAIUM Medial Solutions doctor of any changes in my physical and/or mental state. This includes also updating and notifying as to any intended or actual uptake of any new medication, injections, supplements and any other material added to what was declared by me in the questionnaire, as well as any new medical procedures, hospitalizations, adverse side effects, treatments and consultations in any clinic other than PRAIUM Medial Solutions, conventional or otherwise. PRAIUM Medial Solutions reserves the right to stop its own treatment course in cases when the above said might hinder PRAIUM Medial Solutions treatment plan and reduce its chances of success, according to the clinic staff discretion.
I am well aware that withholding information and/or giving false, misleading or incomplete information can cause inaccurate diagnosis, damage my health and/or hinder the success of PRAIUM Medial Solutions treatment.
Signing this form below constitutes my permission and authorization of Dr. Oren Kaholi, including anyone on his behalf, to charge my credit card for any debt not paid during 21 days from receiving the service due to which there is a debt, as well as debt due to any "cancellation in debit" (as defined in the "PATIENT INFORMATION" above), without the need for any further consent, permission or authorization by me.