CLIENT DISCLOSURE AND RELEASE FORM
Modified-Independence, Inc. (“MIE”) consults with individuals (Client”) to evaluate any existing or potential safety hazards and to recommend modifications to eliminate or reduce the safety hazard and promote independence in activities of daily living.
As part of MIE’s consultation, MIE will provide Client with pictures of the recommend equipment or products along with a list of company websites where the recommended equipment and/or products may be purchased. MIE does not have financial relationship with any of the companies that are recommended.
Client understands that Client is not required to purchase all the recommended equipment and/or products recommended by MIE.
Client acknowledges that MIE will only make recommendations for the purchase of equipment and/or products and will not be responsible to assemble any equipment or products.
Client has a right to obtain equipment, and/or products from any company of Client’s choosing, including but not limited to, the companies that MIE recommends.
Client understands that MIE does not guarantee the quality of the services, equipment or products provided by the independent companies and is not responsible for the maintenance or the repair of any equipment.
Client also acknowledges that all services performed by and any equipment or products purchased from independent companies are billed separately by these companies.
Client acknowledges and agrees that MIE, its shareholders, employees and agents are not liable for any negligence or problems arising from any services, equipment or products provided by any independent companies. Client hereby releases, forever discharges, hold harmless, and indemnifies MIE from and against any and all liability, claims, demands, rights of action, or causes of action of any kind of nature, whether known or unknown, anticipated or unanticipated, either in law or equity, which arise or may hereafter arise from or are connected with the services, equipment or products provided by independent companies.
