Please type patient or guardian's initials in the space provided. *
These initials are a digital signature indicating: 1. The information provided by the respondent is accurate and complete to the best of their knowledge. 2. The Patient and Patient's Guardian agrees to indemnify and hold harmless the Treating Doctor and his staff, organization and consultants of and from any and all claims, demands, losses, causes of action, damage, lawsuits, judgments, including attorneys' fees and costs, arising out of or relating to the work performed by the Treating Doctor and his staff, organization and consultants.