I/We do hereby consent to and authorize the performance of all treatments, and medical services deemed advisable by the physicians and staff of Helium Medical to me or to the above-named minor of whom I am the parent or legal guardian. I hereby certify that, to the best of my knowledge, all statements contained hereon are true. I understand that I am directly responsible for all charges incurred for medical services for myself and my dependents regardless of insurance coverage, excluding only authorized services provided under a valid prepaid HMO contract. I furthermore agree to pay legal interest, collection expenses, and attorneys’ fees incurred to collect any amount I may owe. I also hereby authorize Helium Medical to release information requested by the insurance company and/or its representatives. I fully understand this agreement and my consent will continue until cancelled by me in writing.
