I hereby authorize Al Massa Polyclinic to carry out ,radical examination , investigation , medical treatment , and diagnostic procedures during the course of my care be deemed advisable or necessary with no guarantees about the final results of the treatment. I consent to pay all charges of the services that will be rendered to me according to clinic's regular price list.

I confim that I am the patient ( or the patient's parent or guardian if the patient is under ( 18 years of age), I hereby consent to and authorize the medical provider, its agents , health professionals or other relevant administrative establishment to provide and discuss any health /treatment / billding details, medical records or discharge arrangements ( past or present ) with and to the insurer and / or Third Party Administrator about me and / or any of my family members . I hereby allow Payers and their agents authorized personnel to obtain any requisite medical details from my current and previous physician and case file.

i also understand that the medical expenses coverage is as per stipulated terms and conditions in insurance policy and if there is any execess , charges , expenses not covered in the policy.

I hereby agree that it will be borne by me/my dependents / or others .

I agree that a copy of this consent shall have the validity of the original. I received a copy of Bill of Patient & family Rights and Respnsibilities and explained by the clinic staff.

Patient's Signature:

Date:

If the patient is a Minor or if this consent is signed by a Personal Respersentative on behalf of the patient , please complete the following

Signature of Parent , Guardian or Next of Kin

Printe name of Parent , guardian or Next of Kin

Relationship to Patient

Date: