I, ______________________________,  agree to indemnify, defend, protect, and hold harmless the medical providers employed by Always There Telecare; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Always There Telecare; rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed by Always There Telecare; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Always There Telecare;. I am aware of the potential side effects associated with pharmaceutical treatments, and accept all the risks involved in taking the medication and will not seek indemnification or damages from the indemnified parties.

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Name:__________________________________

Signature:______________________________  Date:____________

Witness:______________________________  Date:____________