I, agree to indemnify, defend, protect, and hold harmless the medical providers employed by Eugenia Thorne, Medical Excellence Wellness and Healthcare and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Eugenia Thorne, Medical Excellence Wellness and Healthcare; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by Eugenia Thorne, Medical Excellence Wellness and Healthcare harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Eugenia Thorne, Medical Excellence Wellness and Healthcare I am aware of the potential side effects associated with IV infusion and injectable therapies provided by Eugenia Thorne, Medical Excellence Wellness and Healthcare, accept all the risks involved with IV infusion and injectable therapies, and will not seek indemnification or damages from the indemnified parties.
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I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.
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