The EHVR Direct Primary Care Pilot – Contractual Agreement

Please ensure that you read through the Participant Terms and Conditions before you complete and sign the form below. YOUR ATTENTION IS PARTICULARLY DRAWN TO THE PROVISIONS OF clauses 2 (which sets out the purpose of this Study), 3 (which describes some of the risks that you assume by participating in this Study), 5 (which affirms the voluntary nature of your participation in this Study and your ability to withdraw at any time), 7.1.8 (which lists the services which will be provided and those which will not be provided to you as part of the Study), 10 (which sets out the amounts you will be liable to pay for being provided Services as part of the Study and in which you provide your authorisation for such amounts to be debited from your bank account) and 13 (which limits the liability of the persons who are undertaking, or participating in the undertaking of, this Study or providing Services to you). Notwithstanding this, you should read the below terms and conditions (which are binding as a legal contract) in their entirety and contact us if anything is unclear or requires further discussion. Your participation in the Study and purchasing of Services is on the terms of, and subject to the conditions set out in this Agreement.

View/Download the EHVR DPC Pilot Participant Agreement

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Participant Type

Personal Details

First Name

Last Name

Date of Birth

Gender Identity

Contact number

Email address

Dependent’s Details

First Name

Last Name

Date of Birth

Gender Identity

Contact number

Email address

Dependent type More info

Main Member’s Details

Full Name

Phone Number

Main Member’s

Signature

I hereby acknowledge and confirm that I: (i) have read and understood the terms of my participation in the Study as set out below; (ii) consent to my participation in the Study and (iii) understand that in the case of an emergency or if I require immediate medical intervention, I should not attempt to use the Services but instead I should call an ambulance and/or visit my nearest emergency department as Epione does not provide any emergency services.