1. To provide accurate & complete information, to the best of your knowledge, about complaints, past illness, hospitalizations, medications, & other matters related to the patients health to the health care provider.

2. To inform if you are currently consulting / under the care of another health professional or provide in connection or any other complaint.

3. To accept all the consequences of your own informed decisions.

4. To take responsibility for the payment of all medical & laboratory expenses incurred for your health care as promptly as possible, save & expect the amount you have been allotted against prior written authorization from a third party.