COMPREHENSIVE RELEASE
READ CAREFULLY – By signing this form, you are agreeing to release and indemnify Bay Hill Psychiatric Associates, LLC, Orlandopsychiatrist.net, psychiatricclinic.net, Syeda N. Sultana, M.D, her providers, Associates, and staffs from liability, to follow safety protocols and assume all risks while attending Out Patient in-person office visit.
As an outpatient participant in an activity to visit our facility, Psychiatric Clinic.net DBA Bay Hill Psychiatric Associates, LLC a Florida Limited Liability Corporation, located at 2869 Wilshire Drive, Orlando, Florida, 32835, and/or as a Patient, parents/guardian, children, spouse/partner or guest of the property, facilities, and services of Psychiatricclinic.net,
As the “Participating Patients”, I agree to the following:
1. AGREEMENT TO FOLLOW DIRECTIONS. I agree to observe and obey all posted rules and warnings, and to follow any oral instructions or directions given by the staff of Psychiatricclinic.net or the host location.
COVID-19 SAFETY INFORMATION:
While attending an onsite or offsite visit, I agree to strictly adhere to all current Centers for Disease Control (CDC) guidelines for COVID-19 (https://www.cdc.gov/coronavirus/2019-nCoV/index.html), and/or preventative measures put in place to reduce the spread of COVID-19. PsychiatricClinic.net cannot guarantee that you will not become infected with COVID-19.
2. CERTIFICATION
By attending an in-person visit at PsychiaticClinic.net, you certify that you have not been exposed to a confirmed or suspected case of COVID-19 or have not been diagnosed with COVID-19, within fourteen (14) days of the event. Individuals who fall within the CDC definition of People at Increased Risk or People Who Need Extra Precautions for COVID-19 (https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html), should seek medical clearance to attend the event or participate in the activity.
By attending an in-person visit or visits each day, the patient warrants that he/she is not experiencing symptoms of COVID-19. Common symptoms of COVID-19 can be found at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. The patient agrees to contact PsychiatricClinic.net if he/she experiences symptoms of COVID-19 within 14 days after participating in-office visits.
3. INDEMNIFICATION. I agree to indemnify and defend PsychiatricClinic.net against all claims, causes of action, damages, judgments, costs, or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family's use of or presence upon, the facilities of PsychiatricClinic.net office location.
4. ENFORCEABILITY. The invalidity or unenforceability of any provision of this Agreement, whether standing alone or as applied to a particular occurrence or circumstance, shall not affect the validity or enforceability of any other provision of this Agreement or of any other applications of such provision, as the case may be, and such invalid or unenforceable provision shall be deemed not to be a part of this Agreement.
5. DISPUTE RESOLUTION. This Agreement shall be construed and controlled by the laws of the State of Florida. The parties will attempt to resolve any dispute arising out of or relating to this Agreement through negotiations amongst the parties. If the matter is not resolved by negotiation, the parties will resolve the dispute using the Alternative Dispute Resolution procedure.
Any controversies or disputes arising out of or relating to this Agreement will be submitted to mediation in accordance with any statutory rules of mediation. If mediation is not successful in resolving the entire dispute or is unavailable, any outstanding issues will be submitted to final and binding arbitration under the rules of the American Arbitration Association. The arbitrator's award will be final, and judgment may be entered upon it by any court having proper jurisdiction.
6. RELEASE AND WAIVER.
I HEREBY WILLINGLY, FREE FROM DURESS, RELEASE, WAIVE AND FOREVER DISCHARGE ANY AND ALL LIABILITY, CLAIMS, AND DEMANDS OF WHATEVER KIND OR NATURE AGAINST PSYCHIATRICCLINIC.NET AND ITS AFFILIATED PARTNERS AND SPONSORS, INCLUDING IN EACH CASE, WITHOUT LIMITATION, THEIR DIRECTORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AND AGENTS (THE “RELEASED PARTIES”), EITHER IN LAW OR IN EQUITY, TO THE FULLEST EXTENT PERMISSIBLE BY LAW, INCLUDING BUT NOT LIMITED TO DAMAGES OR LOSSES CAUSED BY THE NEGLIGENCE, FAULT OR CONDUCT OF ANY KIND ON THE PART OF THE RELEASED PARTIES, INCLUDING BUT NOT LIMITED TO DEATH, BODILY INJURY, ILLNESS, ECONOMIC LOSS OR OUT OF POCKET EXPENSES, OR LOSS OR DAMAGE TO PROPERTY, WHICH I, MY HEIRS, ASSIGNEES, NEXT OF KIN AND/OR LEGALLY APPOINTED OR DESIGNATED REPRESENTATIVES, MAY HAVE OR WHICH MAY HEREINAFTER ACCRUE ON MY BEHALF, WHICH ARISE OR MAY HEREAFTER ARISE FROM MY PARTICIPATION WITH THE IN-PERSON OFFICE VISIT OR ACTIVITY.
7 ASSUMPTION OF THE RISK. I acknowledge and understand the following:
In-person office visits include possible exposure to and illness from infectious diseases including but not limited to COVID-19. While following rules and personal discipline may reduce this risk, the risk of serious illness and death is not completely eliminated. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault associated with the in-person office visit activity, including any injury, harm, and loss caused by the negligence, fault, or conduct of any kind on the part of The Released Parties.