Contract for the provision of medical services

nr……….

Concluded on the……….2014 in Jelenia Góra between:

KCM Clinic S.A. ul Bankowa 5-7 in Jelenia Góra,

established on the basis of registration number KRS Nr:

00000396826; REGON: 021685332; NIP: 611-272-20-32

hereinafter referred to as the “Healthcare Provider”,

represented by:

Monika Mikulicz-Pasler

Head of the Board

and

Patient: __________________________________

Address:__________________________________

§ 1

1.Subject of the contract is the payable execution of

medical services for the Patient (name)

_________________________________________

Medical service: ____________________________

Signature (Doctor): _________________________

Before the operation (mentioned in 1§) the Patient is

obliged to:

a) Pay the Healthcare Provider for the medical

services. (Amount specified in § 4. Point 1 of

the contract)

b) Prepare for the surgery (according to the

recommendations of the doctor), provide the

Clinic with fully and solid health information

and passed diseases.

2.The Healthcare Provider is obliged to carry out the

surgery/treatment with the highest precision and

according to:

- The laws and regulations of Poland

- Indications of current medical knowledge

- Professional ethics rules

3. The Healthcare Provider is not liable for unpredictable

post-operative effects of the treatment/surgery.

§3

Foreseen date of the surgery/treatment:

______________________________________________

§4

1.The Patient covenants to pay the Healthcare Provider

the amount________________________ in

words)__________________________________

2. The amount which is contained in point 1, can increase

in case of additional, unforeseen and necessary medical

services.

§5

The amount mentioned in § 4. Point 1 should be paid

after signing the contract and before the

surgery/treatment which is mentioned in § 1 Point 1.

The payment mentioned in Point 1 should be performed

on the bank account of the Healthcare Provider or Clinic:

SWIFT ALBPPLPW

IBAN Account Number:

PL 32 2490 0005 0000 4520 5253 6195 (PLN)

PL 80 2490 0005 0000 4600 2428 5846 (USD)

PL 84 2490 0005 0000 4600 6111 9390 (EUR)

Or in the reception of the Healthcare Provider 8:00am. -

19.35 pm.

3. The confirmation of the payment has to be present at

the admission to the Clinic.

§6

1.Both sides have the right to cancel the contract

minimum 3 days before the surgery/treatment (mentioned

in § 1 Point 1).

2. The contract can be cancelled at any time with the

consent of both parties.

3.For damages in connection with the dissolution of the

contract as specified in Point 1, the Healthcare Provider is

entitled to compensation of the amount which actually

incurred and the extra costs associated with readiness for

work and administrative costs based on a calculation.

§7

Matters which are not covered by the agreement are in

force of: the provisions of the Civil Code, the Law on

Healthcare and other applicable law.

§8

Disputes arising in the course of performance of the

contract shall be settled by the court competent for the

Healthcare Provider.

§9

1. This contract is claimed to be valid in writing.

Changes and additions to the contract require a

written form to be valid.

2. This contact is created in 2 copies, one for each

party.

Healthcare Provider ____________________

(signature)

Patient ____________________

(Signature)