consent by ashrafp


									                   MEDSTATS INTERNATIONAL, LLC CONTRACT

I, ________________ being of sound mind and legal age and/or also legally responsible
parent/guardian of my son _________________ or daughter _____________________,
confirm that I have read this acknowledgement Document and fully understand that I am
responsible for the most updated status and accurate data presented to Medstats
International LLC.

I understand that this medical application form/data will be processed and sent to me alone
in the various formats requested. I fully understand that unless required by law, this data
will not be shared with any other third party.

I am fully aware that my date of birth and social security numbers are not documented on
my cards/data/autocards/flash drive in an effort to protect my identity.

I am also submitting a personal labeled photograph of each applicant necessary for the
purpose of verifying my/our identities should we be incapable of confirming our identities in
an emergency.

I will assume full responsibility for the maintenance and upkeep of the confidentiality of the
data documented in their multiple forms and returned to me for my possession.

I also fully comprehend that when ordering and purchasing a Medstats Auto Card, I am
totally aware, acknowledge, and consent to its removal from my automobile for the purpose
of facilitating my care by emergency medical and lay personnel.

I also fully understand that Medstats International LLC cannot be responsible for any
unknown third party taking this data from my automobile.

I also fully understand that the cards may not always be accessible to a third party due to
unusual circumstances, e.g. totally inaccessible to shattered windshield, fire, water hazards,
or other circumstances which may render the data cards inaccessible.

I fully indemnify Medstats International LLC and its Directors, Officers, or Employees from
any circumstances that may render the data inaccessible and document (with my signature)
that I cannot hold Medstats International LLC responsible for such happenings which may
render the data null and void.

Furthermore, I fully understand my responsibility to immediately advise Medstats
International LLC of any change in my medical condition, medications, allergies, new
surgeries, or any other changes relative to your health.

It is my expectation that I will receive a book of notification coupons to assist me in
updating Medstats Card International regarding any changes in my/our medical data.
    1. Any changes will immediately be written on the data notification coupon and placed
       on my Medstats card to inform all parties of these cahanges in my medical data.
    2. I will also immediately notify Medstats International LLC by fax, registered mail
       (return receipt requested)or by logging onto and entering
       your user name and password, to facilitate the timely issue of new updated cards.

MedStats International LLC                                                           Page 1
I confirm the acknowledgement of each/all of the above, and confirm my knowledge and
awareness of my responsibility to notify Medstats International LLC of these changes in my
medical condition as soon as they occur.

I hereby indemnify Medstats International LLC, its Directors, Officers, and Employees
against any consequence arising from a failure of the Medstats system.

I warrant that I am duly authorized to act/sign on behalf of all persons listed in the
application, whether they be a spouse, a minor, or persons of limited capacity. I warrant
that all of the information contained in this application is true and correct and I hereby
indemnify Medstats International LLC, the Directors, co-directors, officers, or employees
against any consequences that may arise as a result of a breach of this warranty, and no
legal action, suit at law, or other proceedings will be brought against Medstats International
LLC in consequence, therefore, and I undertake not to hold to the contrary.

I _________________________ of legal age and capacity, confirm that I have read the
information as it pertains to me in the application, concerning its trust and accuracy, and
hereby indemnify Medstats International LLC.

On    behalf   of   my    spouse      _____________________________                   signed
________________________,  we    sign    on  behalf  of  our  minor                  children

I acknowledge that the information contained in the application form will be processed by
Medstats International LLC and recorded in one or more of the following forms: cards, auto
cards, passport cover, kiddy cards, flash drive and any other forms Medstats International
LLC may choose to produce.

It shall be my sole responsibility to procure that information document so returned to me
(whether in request of my own use or that of my spouse, children, or other persons), and I
shall ensure that they shall at all times be appropriately kept and displayed in accordance
with the instructions transmitted in writing to me by Medstats International LLC and such
instructions which may be changed from time to time.

I confirm that Medstats International LLC have undertaken that (unless required by law) the
information given by me in the application form will not be transmitted to any third party
without my written consent.

This document contains the entire contract between the parties. No representations have
been made outside the contract. It can only be changed by documentation in writing,
signed by all parties.

This shall be issued from Medstats Card International, LLC, 6757 Arapaho Road, Suite 767,
Dallas, Texas, 75248, Phone: (877) 412-6363 and governed by the laws of the State of
Texas. This represents the entire and sole agreement between Medstats International LLC
and the applicant, and shall be recognized and administered according to the laws of the
State of Texas.

Signature: ______________________________________________________________

Relationship to pary; (self, mother, guardian, etc)_______________________________

Date: __________________________________________________________________

MedStats International LLC                                                           Page 2

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