CONSENT AND ACKNOWLEDGEMENT

1. I the patient, acknowledge Dr. Cordima/staff has clearly explained the details of the program throughout this agreement and they have also clearly explained that Dr. Cordima may not be in my insurance network and it is possible that I will not receive any insurance reimbursement for this program. I realize that this is purely a decision made by the insurance company and not Dr. Cordima. I understand that my health insurance coverage has certain restrictions and limitations, such as authorization requirements, non-covered services and supplies and I agree to be financially responsible for any and all related charges.

2. I also understand that if I choose to use an outside financing source that it is separate and distinct from Dr. Cordima and not backed by Dr. Cordima. No different than financing an automobile. I have been informed and agree to the fact that my financing will be processed and my program paid in full on the day that I complete the financing paperwork.

3. With my signature below I also give my consent to receive the treatment protocol listed on the previous page & acknowledge that all of my concerns and questions have been completely and thoroughly answered by Dr. Cordima/staff. I understand the objectives of this program being to relieve my pain and increase my nerve function. While it is expected that we will meet our objectives for improvement I also understand that It’s possible, while unlikely, that I do not receive improvement and may even feel worse after the program is completed. I am entering this program hopeful yet with the full understanding that my expectations may not be met and fully are aware of the possible outcomes. No guarantees or assurances have been made concerning the results of the procedures. The response you get from any treatment plan is directly related to the commitment you give to that program.

4. I understand and agree that any refund I am entitled to is contingent upon me doing as reasonably instructed by the doctor. In the event I fail to follow the reasonable instructions of the doctor or alter treatment schedule as originally designed by the doctor and scheduled with the clinic front desk, I agree that the clinic should not be penalized by my failure to execute these things that I have agreed to do in turn and I agree to forfeit my entitlement to any refund. Due to unforeseen circumstances where refunds are necessary, they are calculated based on visits and treatments not used and the fees associated with those unused treatments as well as any equipment/training received. In the event of a pre-payment , the following terms shall apply: (1) pre-payments shall be construed as credit balances only; (2) any unapplied or unused portion of the credit balance shall be refunded to you within thirty (30) days upon request; (3) any patient discontinuing care early shall forfeit the prompt pay discount and will pay for services rendered at regular office fees; (4) pre-payments shall not be construed, or relied upon by you, as either insurance, Health Savings Account, Health Discount Plan, any form of Trust, or as any type of plan which might create a fiduciary duty by our Office to you.

5. By my signature below I also agree in the event that there is any controversy, dispute or claim between Dr. Cordima or their representatives or anyone affiliated with Dr. Cordima and any other party including myself arising from or involved treatment or care at Dr. Cordima shall be resolved only by binding arbitration, and shall be submitted to the American Arbitration Association for arbitration which shall be conducted in accordance with the Association’s rules in effect at the time of applying for arbitration. I understand the arbitral award is final and binding upon both parties and that a demand for arbitration must be in writing & must be made by the aggrieved party within ninety (90) days of the event giving rise to the demand.