RELEASE Permission is granted to download, print or otherwise copy this form for your personal use. In consideration of the payment to me of the sum of dollars ($__________), and other good and valuable consideration. I, being of lawful age, have released and discharged, and for my heirs. executors, administrators and assigns release and forever discharge_________________ and any other person, and his/her/their successors, assigns, heirs, executors, and administrators from any and all actions, claims of action or demands for damages, costs. loss of use, loss of services, expenses, compensation, consequential damage or any other thing whatsoever, on account of or in any way growing out of any known or unknown personal injuries, death or property damage resulting or to result from an occurrence, treatment, or lack thereof, by Dr._______________ his agents, employees, independent contractors, or professional corporation, and which occurrence, treatment or lack thereof spanned a period of time from approximately _______________________________, 19__ to ______________, 19__. I hereby acknowledge and assume all risk that the said injuries or damages may be or become permanent, progressive, or more extensive than is now known or expected. No promise or inducement which is not expressed in this agreement has been made to me and, in executing this release, I do not rely on any statement or representation made by any person, firm, or corporation hereby released, or any agent, physician, dentist or any other person representing any of them, concerning the nature, extent or duration of said damages or losses or the legal liability therefor. I understand that this settlement is the compromise of a doubtful and disputed claim, and that the payment or forgiveness of payment or debt owed is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released and by whom liability is expressly denied. This release contains the ENTIRE AGREEMENT between the parties and the terms of this release are contractual and not a mere recital. The parties hereby acknowledge that this release and payment hereunder are not being made as a result of any written claim or demand. I have carefully read the foregoing release and understand the contents thereof, and I sign as my own free act. Dated this ______ day of _________________, 19__, in the city of _________________County, State of ___________________. Patient Signature WITNESSES: Witness Address To Consent Library