PATIENT INTAKE FORM TEMPLATE
Effective Date: [Date]
1. PARTIES
1.1 This Patient Intake Form Template ("Agreement") is made as of [Date] by and between:
[Party A Full Legal Name] ("First Party"), an individual residing at [Address];
and
[Party B Full Legal Name] ("Second Party"), [an individual/organization] located at [Address].
1.2 The Parties agree to the following terms and conditions:
2. PURPOSE AND SCOPE
2.1 The purpose of this Agreement is to establish the terms under which [describe the arrangement, service, or transaction].
2.2 Specific terms: (a) [Primary obligation or right granted]; (b) [Secondary terms and conditions]; (c) [Duration, timeline, or schedule of performance]; (d) [Location or venue, if applicable].
2.3 Any modifications to the scope of this Agreement must be agreed upon in writing by both Parties.
2.4 This Agreement is personal to the Parties and may not be assigned without prior written consent.
3. FINANCIAL TERMS
3.1 [Payment/Compensation/Fee] amount: $[Amount].
3.2 Payment schedule: [Describe payment timing — upfront, installments, upon completion].
3.3 Payment method: [Cash/check/electronic transfer/credit card].
3.4 Refund policy: [Describe conditions for full or partial refund].
3.5 Additional costs or expenses, if any, shall be [borne by/shared between] the Parties as follows: [Details].
4. RESPONSIBILITIES AND OBLIGATIONS
4.1 First Party shall: (a) [Primary responsibility]; (b) [Secondary responsibility]; (c) [Compliance obligations].
4.2 Second Party shall: (a) [Primary responsibility]; (b) [Secondary responsibility]; (c) [Cooperation and communication obligations].
4.3 Both Parties agree to act in good faith and communicate promptly regarding any issues that arise during the term of this Agreement.
5. LIABILITY AND ASSUMPTION OF RISK
5.1 Each Party acknowledges the inherent risks associated with [relevant activity or transaction] and agrees to assume such risks.
5.2 [Releasing Party] hereby releases and holds harmless [Released Party] from any claims, injuries, damages, or losses arising from [specific activity], except those caused by gross negligence or willful misconduct.
5.3 Each Party shall be responsible for maintaining appropriate insurance coverage for their respective obligations and property.
6. TERM AND TERMINATION
6.1 This Agreement shall be effective from [Start Date] through [End Date], unless terminated earlier.
6.2 Either Party may terminate this Agreement: (a) By mutual written consent; (b) Upon [14] days' written notice to the other Party; (c) Immediately if the other Party breaches a material term.
6.3 Upon termination, each Party shall return any property belonging to the other Party and settle any outstanding financial obligations.
7. DISPUTE RESOLUTION
7.1 The Parties agree to attempt to resolve any disputes through good faith negotiation.
7.2 If negotiation fails, disputes shall be submitted to [mediation/binding arbitration] in [Location] under [applicable rules].
7.3 The prevailing Party in any dispute shall be entitled to recover reasonable attorneys' fees and costs.
8. GOVERNING LAW
8.1 This Agreement shall be governed by and construed in accordance with the laws of the State of [State/Jurisdiction], without regard to its conflict of law provisions.
8.2 Any disputes arising under or in connection with this Agreement shall be resolved in the state or federal courts located in [County], [State], and each Party hereby consents to the jurisdiction of such courts.
9. SEVERABILITY
9.1 If any provision of this Agreement is held to be invalid, illegal, or unenforceable, the remaining provisions shall continue in full force and effect.
9.2 The invalid or unenforceable provision shall be modified to the minimum extent necessary to make it valid and enforceable.
10. ENTIRE AGREEMENT
10.1 This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior negotiations, representations, warranties, commitments, offers, and agreements, whether written or oral.
10.2 No amendment or modification of this Agreement shall be valid unless made in writing and signed by both Parties.
SIGNATURES
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the date first written above.
[Party A Name] Signature: ___________________________ Name: [Full Legal Name] Title: [Title/Position] Date: [Date]
[Party B Name] Signature: ___________________________ Name: [Full Legal Name] Title: [Title/Position] Date: [Date]
DISCLAIMER: This template is provided for informational purposes only and does not constitute legal advice. Consult a qualified attorney before using this document to ensure compliance with applicable laws in your jurisdiction.
