ExecutiveCheckUp_Dec4_Men_EnglishVersion 2

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Commitment Form – Result ConsultationThis commitment form is to allow Healthcare System Novomed Centers to provide medicalinformation to the certain person mentioned below. Novomed Centers will never provide your medicalcheck up results and consultation information to a third party except the person below. If theresults are disclosed or destroyed due to any other reasons below, Novomed Centers shall not bea. 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 appointName:Address:Tel:Relationship:As my true and lawful attorney, with full power and authority to have the test results (Date ofexamination (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)SignatureIf 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 withAny and all legal hearings will only be tried under the jurisdiction of UAE law.
Suite 3002 – 300 th Floor, Marina Plaza,Dubai Marina, Dubai, UAE800 NOVOMED (668 6633) @novomedcenters www.novomed.com
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