Release and Waiver of Liability

RELEASE AND WAIVER OF LIABILITY

I understand that all the examination and screening services including any information (the “Service”) provided by CheckMyHeart, LLC, are meant to serve for screening results only and do not constitute a diagnosis of my health status. I hereby consent to the following services to be provided:

□EKG   □ECHOCARDIOGRAM □CAROTID DOPPLER  □ABDOMINAL AORTIC U/S

Other Screening service_________________________

Your Representation and Acknowledgment

I clearly understand that none of the services offered by CheckMyHeart, LLC is to be substituted for services provided by a Medical Provider or serve as a replacement for a Medical evaluation. I understand that the services I will be receiving from CheckMyHeart, LLC are not offered as a substitute for professional advice by a medical expert, physician or other qualified professionals and will seek independent professional guidance for such matters. I understand that I should never delay in getting a professional medical advice, nor delay in seeking it, because of the results provided to me or something I have learned, viewed, listened to, read or otherwise ascertained or obtained from or based on any services of CheckMyHeart, LLC, any engagement or any information conveyed to me by CheckMyHeart, LLC. Any result from CheckMyHeart, LLC, information is not intended to replace the services of a trained professional or be a substitute for the advice of physicians. CheckMyHeart, LLC makes no representations or warranties with respect to the results provided or any information or services offered or provided to me.

I understand that the result of these test whether normal or abnormal will be provided to me as part of the service and CheckmyHeart LLC, Owner and Employees have not verbally or in any way provided or suggested medical services to me. I acknowledge that it is my responsibility to seek further medical opinion and treatment via a qualified medical provider if results are abnormal.

I understand that CheckMyHeart LLC will only provide the results to me and will not forward the results or any part thereof to any 3rd Party or Medical Service Provider.

Waiver and Release.

In consideration of the provision of the Service, I hereby release and forever discharge and hold harmless CheckMyHeart, LLC and its successors and assigns from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my use of this Service.

I understand and acknowledge that this Release discharges CheckMyHeart, LLC from any liability or claim that the I may have against CheckMyHeart, LLC with respect to any bodily injury, personal injury, illness, death, losses, or damage that may arise in connection with my reliance on the results or any information provided to me, whether caused by the negligence of CheckMyHeart, LLC or its officers, directors, employees, or agents or otherwise.

Governing law.

I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State where the service was provided and that this Release shall be governed by and interpreted in accordance with the laws of the State of the service location. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

I understand that this is a screening service only, not a physician visit or a doctors office, and I waive any HIPPA laws that may be applicable to the services provided by CheckMyHeart LLC.

IN WITNESS WHEREOF, I have executed this Release as of the day and year first above written.