Form Validation
Clicking on this box constitutes a signature agreeing to the following statement: *
"I am the person whose name appears on this form and that all information is correct to the best of my knowledge. In addition, I understand that Cosmetic Surgery Recovery Suites LLC ("CSRS") is a luxury service (not a medical service or medical provider) intended to provide a comfortable and private setting to assist with mental and physical recovery following outpatient cosmetic surgery procedures. I understand that CSRS is not a substitute for medical care or hospitalization and, as such, I am electing to use the services of CSRS as a matter of convenience and not for reasons related to medical care. I hereby acknowledge that I am of legal age and of sound mental capacity and that I make this election free from any duress or undue influence.
I understand that all services offered and/or provided by CSRS are provided exclusively by CSRS and are not provided by Drury Inn & Suites-Columbus Convention Center, Drury Inns, Inc., and/or any of its or their affiliates or employees (collectively, “Drury”); without limiting the foregoing, I understand and agree that Drury is not in any way affiliated or associated with, and does not sponsor, any of CSRS’ services and, further, that Drury is merely providing a hotel room, as it would to any hotel guest, and does not provide any other services (including, but not limited to, medical or nursing), does not provide or monitor the call service, does not enforce the visiting hours established by CSRS, does not ensure the privacy of CSRS clients, and does not monitor, evaluate the suitability of, supervise, or in any manner control, direct, or monitor the actions of any client and/or employee, independent contractor, agent, or affiliate of CSRS. I understand that Drury has not evaluated whether its facilities are suitable for the services provided and/or offered by CSRS, all such evaluations and determinations having been made exclusively by CSRS, and that Drury expressly disclaims any and all representations and warranties regarding the suitability of its facilities for these purposes.
I agree, on behalf of myself, any family members, my heirs, successors, and assigns, to indemnify and hold harmless Drury and all of its owners, agents, officers, directors, employees, subsidiaries, and affiliates (each a “Drury Indemnified Party”) from and against any and all loss, liability, damage, cost, expense (including reasonable attorneys' and expert witness’ fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission, or state of facts and/or any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I may sustain: (1) in connection with, as a result of and/or otherwise arising out of any services provided to me by CSRS; (2) in connection with, as a result of and/or otherwise arising out of any failure of CSRS to provide any services or care to me; (3) CSRS’ negligence, misconduct, intentional conduct, and/or actions; and/or (4) in connection with, as a result of and/or otherwise arising out of my surgery, my outpatient recovery care, and/or my post-operative medical treatment Further, I understand that although CSRS is owned by a physician, my medical care, at all times, and in all circumstances, remains the responsibility of the surgeon who performed my surgery. I understand that only my surgeon is authorized to write prescriptions for me and to determine if outpatient recovery care is appropriate for my particular recovery needs. I understand that my surgeon is the only party with the authority to order and perform post-operative medical treatment and he or she reserves the right, alone, to order my hospitalization, if that is the level of care I require. I further understand that my surgeon is the only party authorized to determine the level of post-operative care needed following my procedure, including whether discharging me to a non-medical facility, such as home or CSRS, is appropriate.
I understand that I may be unsteady on my feet following surgery and I agree to request assistance getting out of bed for the first 24-hrs following surgery. In addition, while on pain medication, I agree to remain in my recovery suite at CSRS unless accompanied by a friend, family member or CSRS nurse.
In consideration of the foregoing, I still elect to utilize the services of CSRS. I agree to indemnify and hold harmless CSRS and all of its owners, agents, officers, directors, employees and affiliates from and against any and all loss, liability, damage, cost, expense (including reasonable attorneys' fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission or state of facts and any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I may sustain in connection with the services provided to me by CSRS or any of the foregoing.
In addition, I fully understand that it is MY responsibility to check with my surgeon, prior to my surgery date, for verification on which over-the-counter AND prescription medications I may take while recovering at CSRS. I agree to ONLY bring over-the-counter & prescription medications, to CSRS which my surgeon has verified I may safely restart on arrival to the facility. I understand that it is my responsibility to place ALL approved medications, BOTH prescription and over-the-counter, in ONE MEDICATION BAG that will be given to CSRS staff on arrival. Furthermore, I agree that I will not self-administer medication of any kind during my recovery and that by choosing to do so, I am jeopardizing my own health and safety. I hearby agree to indemnify and hold harmless CSRS and all of its owners, agents, officers, directors, employees and affiliates from and against any and all loss, liability, damage, cost, expense (including reasonable attorneys' fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission or state of facts and any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I may sustain in connection with choosing not to comply with CSRS's medication policy stated here.
Further, I understand that CSRS has a strict NO SMOKING policy and I will be fined $250 if caught smoking in my room. I understand that smoking causes significant detriment to my body's ability to heal and greatly increases my risk of post-op complications. I hereby agree NOT to smoke while at CSRS. I also agree NOT to request the assistance of a CSRS staff member, hotel employee or any other person to assist me outside to smoke. Should I decide to smoke and breech this contract, I am doing so at my own risk. I hearby agree to indemnify and hold harmless CSRS and all of its owners, agents, officers, directors, employees and affiliates from and against any and all loss, liability, damage, cost, expense (including reasonable attorneys' fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission or state of facts and any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I may sustain in connection with choosing to smoke while at CSRS.
I hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in transportation activities involved with CSRS. Further, authorization and permission is hereby given to CSRS to furnish any necessary transportation, and I hereby agree to hold harmless and indemnify CSRS and all of its owners, agents, officers, directors, employees and affiliates for any liability sustained by services provided by CSRS as a result of the negligent, willful or intentional acts of CSRS including expenses incurred attendant thereto and hereby give permission to hospitalize and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. I understand that this is a legally binding release and consent that the transportation services are provided in consideration for this signed release and consent. I have carefully read this Release of Liability and Consent for Transportation and Medical Treatment policy, outlined here and fully understand its contents. Being aware of said contents, I sign of my own free will. I understand that whenever myself, a family member or friend will be transported, that I hereby release and hold CSRS and all of its owners, agents, officers, directors, employees and affiliates harmless from any and all loss, liability, damage, cost, expense (including reasonable attorneys' fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission or state of facts and any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I, a family member or a friend, may sustain in connection with the services provided to me by CSRS or any of the foregoing.
Furthermore, I hereby release and hold each any every Drury Indemnified Party harmless from and against any and all loss, liability, damage, cost, expense (including reasonable attorneys' and expert witness’ fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission or state of facts and any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I, a family member or a friend, may sustain: (1) in connection with, as a result of and/or otherwise arising out of any services provided to me by CSRS; (2) in connection with, as a result of and/or otherwise arising out of any failure of CSRS to provide any services or care to me; (3) CSRS’ negligence, misconduct, intentional conduct, and/or actions; and/or (4) in connection with, as a result of and/or otherwise arising out of my surgery, my outpatient recovery care, and/or my post-operative medical treatment.”" |
