ExecutiveCheckUp_Dec4_Men_EnglishVersion 2

Commitment Form – Result Consultation
This commitment form is to allow Healthcare System Novomed Centers to provide medical
information to the certain person mentioned below. Novomed Centers will never provide your medical
check up results and consultation information to a third party except the person below. If the
results are disclosed or destroyed due to any other reasons below, Novomed Centers shall not be
a. The result incurred due to your negligence in management.
b. Unavoidable circumstance such as natural disasters.
I or (testee), the undersigned, hereby make, constitute, and appoint
Name:
Address:
Tel:
Relationship:
As my true and lawful attorney, with full power and authority to have the test results (Date of
examination (MM/DD/YY): / /20 ; Form as printed version and USB copy)
and medical consultation with one of the center’s physician.
Date: / / 20 (MM/DD/YY)
Testee (or Guardian)
Signature
If you are not the testee yourself, please fill out the following questions.
Relationship with testee:
Address:
Residence ID number:
Phone number:
This request is valid with the testee’s signature or seal, but if the testee is a minor or with
Any and all legal hearings will only be tried under the jurisdiction of UAE law.