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