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“Center for immunocorrective therapy” Ltd OGRN [PSRN] 1097847079110, Fiscal Id No 7807342206, license for medical activities No 78-01-005371dt 12th December 2014, issued by Public Health Committee of Saint Petersburg Government, hereinafter referred as “Provider”, represented by managing Director Mr. Dziaduk Yurii acting ex officio on the one part And ¬¬Mr._ _ _ _ _ _ _ _ _ _ ___________________________bynationality passport No:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Residing at: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ ___, Hereinafter referred as “Customer (Patient)” on the other part have agreed as follows: 1. Objective 1.1 The Customer appoints and the Provider agrees and undertakes to provide for a fee medical care (medical services, including but not limited to: consultative, prevention, diagnostic and treatment, rehabilitation etc.), adequate to the requirements applicable to the techniques of diagnostic, prevention and treatment authorized in Russian Federationin outpatient polyclinic unitsand/or at home to the Customer (Patient)__________________. The Customer voluntarily undertakes an obligation to pay for all rendered medical services (medical care) and transfer servicespursuant to the terms and procedures set forth in this Agreement. 2.1 Customer`s (Patient`s) rights: 2.1.1. To get qualified medical services (medicalcare) and medical consultation; 2.1.2. To refuse medical care at any time; 2.1.3. To get a summary of the qualification and certification of the specialists; 2.1.4 To buy on his own, after attending physician approval, the consumablesand medications, the Provider has not any liability for its quality. 2.2 Customer`s (Patient`s) obligations: 2.2.1. To pay for the rendered medical care (medical services) and medical consultations according to Price-list, effective at the date of signing of Agreement and to buy on his own from the pharmacy chain or from the Provider prescribed medications under specific agreement, according to the individual plan of combined immunotherapy; 2.2.2.To meet the requirements, designed to provide quality paid medical services, which includes the communication of all needed information; 2.2.3. To indemnify the losses in the event if the Patient damages to property of the Provider. 2.3. Provider`s rights: 2.3.1. To decide about duration of treatment, volume of medical services, need to transferring the Patient to a different specialization unit according to his state of health; 2.3.2. In the event of emergenciespresenting a direct risk to life of the Patient, to decide on his own, about the tests, procedures and operative interventions, needed for diagnosis, examination and delivery of health care; 2.3.3 If it is necessary to engage external providers and co-providers to provide medical services if it is agreed between the Patient and the Provider; 2.3.4. To terminate this Agreement upon thebreachby Patient of doctor`s recommendations, techniques and implementation of treatment plan. 2.4. Provider`s obligations 2.4.1. To inform the Patient atadmission for the treatmenton the code of conduct, recommendations and plan of treatment; 2.4.2 To ensure compliance of rendered services under this Agreement with requirements applicable to the techniques of diagnostic, prevention and treatmentin Russian Federation; 2.5. Customer`s (Patient`s) rights: 2.5.1.To get information in a readily understandable form about his state of health, including information about examination results data, presence of the disease, his diagnosis, prognosis, treatment options, related risk, options of medical intervention, its consequences and treatment results. 2.5.2. Patient has the right to the voluntary informed consent for the medical intervention. In the event when Patient`s state precludes him to express his will, and the medical intervention is urgent the case conference shall take decision about its implementation in the interest of the Patient and in specific situations such decision can be taken by an attending (on duty) physician. Refusal of medical intervention shall be documented with indication of potential impacts into medical papers and should be signed by the Patient or his legal representative and by the physician. 2.6Customer`s (Patient`s) obligations: 2.6.1. To get familiar with hospital code of conductand to comply with it; 2.6.2. To respect attending physician`s prescriptions; 2.6.3. To provide in time any information about state of health to the attending physician; 2.6.4. In the event of any change in the state of health to inform the administrator asap on cell phone +7 981 7320251; 2.6.5 To refuse for treatment period: drugs and drug-containing medicaments, psychotropic medications and alcoholic drinks; 2.6.6. To agree with the attending physicianthe use of any treatment medication, medicament, medicinal herb, ointment etc.; 2.6.7 Do not use analgesics and anti-febrile agents. 3. Price and payments 3.1The Customer pays for medical consultation, outpatient polyclinic units services and medical services according to Price-list (see Appendix No 1)established by Provider by cash deposit on bank account or at the Provider`s desk. 3.2. The Customer pays 100% of medical services, treatment cours in an amount of: _______________(_____________________) USD by « __ » _______ 2017 The price may be increasedby agreement with the Customer in the case when additional medical or other services were provided or additional medicaments were prescribed to the Customer. 4. Liability of the Parties 4.1. The Parties are liable for a failure to fulfill or improper fulfillment of the terms herein in accordance with Russian Federation law. 4.2. The “Provider” shall not be liable for the occurrence of any of the events specified below: − Complications arisen through Patient's fault (non-respect physician`s prescriptions); − Untimely informing about any arising health deviation andproblem etc; − Treatment cessationat the Patient`s initiative; − Breach of conditions set forth above into the Clauses 2.3.4., 2.6.1., 2.6.2., 2.6.3., 2.6.4., 2.6.5.,2.6.6.,2.6.7.; 4.3. The Customer (Patient) by signing this Agreement agrees and signs this voluntary informed consent for the medical intervention, for the implementation of the tests, intervention, surgery, treatment under sections 30, 31,32,33 of the Fundamental Principles of Legislation of the Russian Federation on public health of 22.07.1993 No №5487-1. 5.Confidentiality 5.1 The Provider agrees to keep the information secret on the event of Patient`s medical treated case, his health information, his diagnosis and any other information obtained in the course of the tests and treatment. 5.2.With the consent of the Patient or his legal representative it is possible to transfer this informationconcerning medical confidentiality to another person named by Patient or his legal representative. 5.3. Providing information concerning medical confidentiality without Patient`s or his legal representative`sconsent is allowed in cases specified in section 61 of the Fundamental Principles of Legislation of the Russian Federation on public health 6. Term 6.1. This Agreement becomes effective from the moment of its signing and 100% prepayment of medical services by cash deposit on bank account or at the Provider`s desk and remains effective until performance of all obligations by the Parties. 6.2. Initiation of treatment, services from « __» ______ 2019 6.3 End of treatment, services till « __» ______ 2019 7. Otherconditions 7.1. The Customer (Patient)shall be informed on the practices of medical care receiving in Russian Federation, abroad of Russian Federation and on the possibility to receive medical care for free under mandatory medical insurance program. The Customer (Patient) agrees to receive medical care (medical services) from the “Center for immunocorrective therapy” Ltd for a fee. 7.2The Customer (Patient) shall be informed and agreed with the procedure of admission, accommodation and medical care receiving at: _____________________________________ 7.3. The price of the consumables and medications bought by Customer (Patient) on his own is not included into medical services bill. 7.4 The Customer`s (Patient)consent to the medical service implementation and the event of its receiving means in the same time Customer`s (Patient)consent to pay for such service. 7.5The Customer`s (Patient)wishto be accommodated in individual room of the off-side in-patient facility and the event of its receiving means in the same time Customer`s (Patient)consent to pay for such service under specific Agreement. 7.6.The Customer (Patient)agrees to provide information concerning Patient`s medical confidentiality for the “Center for immunocorrective therapy” Ltd uses in order of scientific, educational and practical medicine development in Russian Federation and abroad. 7.7. All other matters not covered by this Agreement shall be governed by the applicable laws of the Russian Federation. 8. Disputes, jurisdiction In the event of any claim against implemented tests, received consultation of the specialists and treatment (in the Patient`s opinion) the Customer`s (Patient) is required to notify thereofon the same day to the attending physician or administrator. The Parties try to settle all disputes under this Agreement in a friendly manner by way of negotiations otherwise all disputes shall be settledin accordance with the applicable legislation of the Russian Federation in Provider's place of jurisdiction. 9. Parties data Provider: “Center for immunocorrective therapy” Ltd Fiscal Id No 7807342206 RRC780201001 OGRN [PSRN] 1097847079110 Business address: 16/2 office 17 N lit. A Engels ave. 194156, Saint Petersburg, RUSSIA E-mail: offis@immunocorrect.ru www. immunocorrect.ru SWIFT: VTBRRUM2NWR JSC VTB BANK (OPERU BRANCH) ST. PETERSBURG BRANCH: Udelny Branch Account number: 40702978880000001731 (EUR) Customer: