I,  the patient,  irrevocably and unconditionally, indemnify Bloemcare directors and staff against injury suffered during my stay in Bloemcare or when using the transport arranged/supplied by Bloemcare.

When leaving the premises with, or without, consent it will be at my own risk. When using the gymnasium it will be at my own risk.

I indemnify the directors and staff against any loss, damage, harm or costs of any nature that I may suffer during my stay.

I, acknowledge the following:

I will be held responsible for payment of the full account, irrespective of my membership at the medical aid and the handling of the account by the medical aid. All costs and disbursements, including legal coasts on attorney-client scale, shall be payable as and when incurred on all arrear accounts. The parties herby choose domicilium citandi et executandi (physical address) for all notices and/or processes to be given and served at their respective addresses referred to herein.

I confirm that the above information is true and accurate.