This survey involve the use of secure interactive electronic equipment.
I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
I understand that I have the right to refuse to participate or decide to stop participating in the survey at any time.I may cancel my survey at any time by contacting River Oaks Plastic Surgery Center at (713) 522-8228
I understand that the laws that protect privacy and the confidentiality of my private information apply to this survey.
I understand that this survey is a screening tool and will not result in any particular treatment recommendation/s.
I acknowledge that taking this survey does NOT establish a doctor – patient relationship
I understand that goal of the screening survey is to ensure that patients with head and neck pain are on the right path toward pain relief which may or may NOT include surgery.
I understand that this survey will be governed by all applicable laws, rules, and policies of the State of Texas. Any dispute between provider and patient will be decided in the State of Texas using the laws of the State of Texas. Additionally, venue for any dispute will be decided in a Harris County state court. Any dispute arising out of or related to this survey, including but not limited to any claim for breach of contract, shall be resolved by binding arbitration in accordance with the rules of the American Arbitration Association. The arbitration shall be held in Houston, Texas, and shall be conducted by a single arbitrator. The arbitrator’s decision shall be final and binding on the parties, and judgment may be entered in any court of competent jurisdiction. The prevailing party in the arbitration shall be entitled to recover its reasonable attorney’s fees and costs.”
By clicking this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction.
This survey involve the use of secure interactive electronic equipment.
I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
I understand that I have the right to refuse to participate or decide to stop participating in the survey at any time.I may cancel my survey at any time by contacting River Oaks Plastic Surgery Center at (713) 522-8228
I understand that the laws that protect privacy and the confidentiality of my private information apply to this survey.
I understand that this survey is a screening tool and will not result in any particular treatment recommendation/s.
I acknowledge that taking this survey does NOT establish a doctor – patient relationship
I understand that goal of the screening survey is to ensure that patients with head and neck pain are on the right path toward pain relief which may or may NOT include surgery.
I understand that this survey will be governed by all applicable laws, rules, and policies of the State of Texas. Any dispute between provider and patient will be decided in the State of Texas using the laws of the State of Texas. Additionally, venue for any dispute will be decided in a Harris County state court. Any dispute arising out of or related to this survey, including but not limited to any claim for breach of contract, shall be resolved by binding arbitration in accordance with the rules of the American Arbitration Association. The arbitration shall be held in Houston, Texas, and shall be conducted by a single arbitrator. The arbitrator’s decision shall be final and binding on the parties, and judgment may be entered in any court of competent jurisdiction. The prevailing party in the arbitration shall be entitled to recover its reasonable attorney’s fees and costs.”
By clicking this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction.
This survey involve the use of secure interactive electronic equipment.
I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
I understand that I have the right to refuse to participate or decide to stop participating in the survey at any time.
I may cancel my survey at any time by contacting River Oaks Plastic Surgery Center at (713) 522-8228
I understand that the laws that protect privacy and the confidentiality of my private information apply to this survey.
I understand that this survey is a screening tool and will not result in any particular treatment recommendation/s.
I acknowledge that taking this survey does NOT establish a doctor – patient relationship
I understand that goal of the screening survey is to ensure that patients with head and neck pain are on the right path toward pain relief which may or may NOT include surgery.
I understand that this survey will be governed by all applicable laws, rules, and policies of the State of Texas. Any dispute between provider and patient will be decided in the State of Texas using the laws of the State of Texas. Additionally, venue for any dispute will be decided in a Harris County state court. Any dispute arising out of or related to this survey, including but not limited to any claim for breach of contract, shall be resolved by binding arbitration in accordance with the rules of the American Arbitration Association. The arbitration shall be held in Houston, Texas, and shall be conducted by a single arbitrator. The arbitrator’s decision shall be final and binding on the parties, and judgment may be entered in any court of competent jurisdiction. The prevailing party in the arbitration shall be entitled to recover its reasonable attorney’s fees and costs.”
By clicking this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction.