Indemnification Clause Final_SUMMIT

I, ______________________________, agree to indemnify, defend, protect, and hold harmless the medical providers employed by Summit Club, LLC, Trilogy Management, LLC, and Patronus Medical; and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical/service providers employed by  Summit Club, LLC, Trilogy Management, LLC, and Patronus Medical rendering medical care, wellness services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical/service providers employed by Summit Club, LLC, Trilogy Management, LLC and Patronus Medical harm or injury resulting from IV therapies, injections, or pharmaceuticals provided directly or indirectly by the medical/service providers employed by Summit Club, LLC, Trilogy Management, LLC and Patronus Medical. I am aware of the potential side effects associated with IV infusion and injectable therapies provided by Summit Club, LLC, Trilogy Management, LLC and Patronus Medical, and accept all the risks involved with IV infusion and injectable therapies, and will not seek indemnification or damages from the indemnified parties.

Printed Name:_________________________________________________________________________

Signature:_____________________________________________________Date:___________________

Witness:______________________________________________________Date:___________________