I am asking for medical care and treatment at this facility, and agree to accept services which may diagnose my medical condition and routine dental and medical care.

* I understand that these services will be provided to me by the Physicians, Nurses, Dentists and other health care providers.

* I understand that my agreement to accept these services is called a general consent and that it includes any routine procedure(s) or treatment(s) such as blood drawing, physical examination, administration of medications, taking x-rays, use of local anesthesia, and other non-invasive procedures, The laboratory has the capability and resources to meet the requirements. Laboratory personnel have the skills and expertise necessary for the performance at the intended examinations. Reference shall be made to any work referred by the laboratory to a referral laboratory or consultant.

* I do acknowledge that different declarations may be needed for some specific diagnostic and surgical procedures

* I further acknowledge, that results of medical treatments and surgical procedures may not be adequately predicted,neither the clinic nor attending medical team can or allowed to give any guarantee or confirmation of outcomes.

I also understand that for services provided through insurance coverage, I am responsible for any copayments & deductibles and that these amounts are due at the time services are rendered, I also understand that in the event that services rendered are not covered under my "insurance", I will accept financial responsibility for all services provided to me. I hereby authorize Magenta Health Plus Clinic, release of all information necessary to secure payments and to reveal my confidential data to my insurance/ employer as part of my insurance policy/ claim (this phrase applies to insured patients only)

I understand that my agreement to accept these services will remain in eflect unless I say that i no longer want the services or until my treatment is completed

* I assume full responsibility for all items of personal property, including but not limited to eye glasses, hearing aids, dentures,jewelry, money and all other valuables

* I understand that there may be personal cost involved in my treatment as per the UAE laws and regulations.

* I have been explained patient's rights and responsibilities.

SUBSTITUTE CONSENT GIVER

If the patient cannot consent for him/ her self, the signature ol the parent, health care provider, legal guardian, or substitute consent giver who is acting on behalf of the patient or the patient's next of kin who is assenting to the treatment for the patient, must be obtained.

I of Nationality years old. Holder of ID: Number Type. do hereby declare that I am the guardian/ substitute consent giver tor the patient in my capacity as l have been asked, in the best interests of the patient, to sign this declaration and consents required by the clinic as the patient is incompetent to do so.

Name and Signature of Substitute Consent Giver

Date