Patient Agreement Form

Please fill-in the form below before calling the priority line

  • The below digital undersigned desires to obtain medical services from Dr. Reza Danesh, M.D. Inc. doing business as MODO Mobile Doctor, (“MODO”), for good and valuable consideration, Patient agrees as follows:

    1. Fees. Patient is fully and personally responsible for the cost of the medical services rendered by MODO to Patient and shall pay the same to MODO at the time of service.

    2. Medical Services. As used in this Agreement, the term medical services shall mean those medical services that MODO is permitted to perform under the laws of the state in which such services are provided and that are consistent with standard acute medical care training. Patient agrees and understands that MODO is not an emergency medical care provider, paramedic, or ambulance service. Patient understands that MODO does not provide transportation. MODO does not represent to be a service provider of any medical specialty and its services shall not be construed to be those of a specialist. Patient understands that it is Patient’s obligation to follow-up with a specialist if specialty care is needed. MODO is not a hospital and does not have access to laboratory monitoring and diagnostics. Patient agrees to be treated without access to the data and facilities that may be available at hospitals which may not be available to

    3. Controlled Substance Prescriptions. Patient understands that: 1. the use of certain medication(s) may cause addiction as well as other negative side effects, some of which can be dangerous; 2. drinking alcohol or using street drugs may result in the inability to think clearly and that Patient could become sleepy and risk personal injury when using certain prescription medication; and 3. Patient may get addicted to medication prescribed to Patient and withdrawal from certain medications can result in illness.
    Patient agrees that he or she is responsible for his or her medicines and will not share, sell, or trade medicine prescribed to Patient. Patient further agrees to disclose to MODO any and all medications that Patient is currently taking and or has been prescribed in the past year.

    4. Mediation. Any and all claims, controversies or disputes arising out of or relating to this Agreement, which remain unresolved after direct negotiations between the parties, shall be first submitted to formal mediation. Mediation shall be endeavored in good faith. Each party shall bear its own costs and expenses (including legal expenses) related to mediation.

    5. Arbitration. In the event that Mediation is unsuccessful, any controversy or claim arising from or relating to this Agreement shall be settled by arbitration administered by either Dispute Resolution Hawaii or the American Arbitration Association and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The arbitration shall take place before a panel of three arbitrators in the State of Hawaii, County of Maui. Each party shall bear its own costs and expenses (including legal expenses), provided that the arbitrator or panel of arbitrators may agree to award the substantially prevailing party its reasonable costs and attorneys’ fees related to the mediation.

    6. Duty of Candor. Patient agrees to answer any medical related questions with absolute candor and honesty.

    7. Privacy. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes certain protocols and restrictions regarding the storage and transfer of medical records. Text and email are not secure methods of conveying records and information. Patient understands the risk that sending medical related information via text or email to MODO may result in third parties being able to read that information. In communicating with MODO via text and or email, Patient knowingly accepts that risk and waives Patient’s rights with respect to those medical records.

    8. Social Media. Patient agrees that MODO may publish to any social media, website and or other media for commercial or advertising purposes any photograph(s) taken by MODO of Patient upon Patient’s oral consent for the same. To that end, Patient grants MODO permission to use Patient’s likeness in a photograph, video, or other digital media (“Photo”) in any and all of its publications, including web-based publications, without payment or other consideration and understands and agrees that all such photos shall become the property of the MODO. Patient waives any right to inspect or approve the Photo(s) wherein Patient’s likeness appears and waives any right to royalties or other compensation arising or related to the use of the Photo(s). Patient hereby holds harmless, release, and forever discharges MODO from all claims, demands, and causes of action which Patient may have by reason of this authorization.

    9. Miscellaneous Provisions.

    9.1 Jurisdiction and Application of Law. Interpretation of this Agreement shall be controlled by the laws of the laws of the United States of America where applicable and the State of Hawaii. Subject to Articles 5 and 6 above, any dispute arising hereunder shall be subject to the exclusive jurisdiction of the Courts of the Second Circuit, State of Hawaii or the United States District Court, District of Hawaii.

    9.2 Amendments. This Agreement may be amended only with the written agreement of the Parties.

    9.3 Construction. Whenever the singular number is used in this Agreement and when required by the context, the same shall include the plural and vice versa, and the masculine gender shall include the feminine and neuter genders and vice versa.

    9.4 Waivers. The failure of any party to seek redress for violation of or to insist upon the strict performance of any covenant or condition of this Agreement shall not prevent a subsequent act, which would have originally constituted a violation, from having the effect of an original violation.

    9.5 Severability. If any provision of this Agreement or the application thereof to any person or circumstance shall be invalid, illegal or unenforceable to any extent, the remainder of this Agreement and the application thereof shall not be affected and shall be enforceable to the fullest extent permitted by law. Without limiting the generality of the foregoing sentence, to the extent that any provision of this Agreement is prohibited or ineffective under act or common law, this Agreement shall be considered amended to the smallest degree possible in order to make the Agreement effective under the act or common law.

    9.6 Heirs, Successors and Assigns. Each and all of the covenants, terms, provisions and agreements herein contained shall be binding upon and inure to the benefit of the parties hereto and, to the extent permitted by this Agreement, their respective heirs, legal representatives, successors in trust, successors and assigns.

    9.7 Electronic Signatures. This Agreement may be executed in counterparts, each of which shall be deemed an original but all of which shall constitute one and the same instrument. Electronically transmitted signatures (e.g., by facsimile or email) shall have the same force and effect as original signatures.

    The completion of the form below will act as your electronic signature acknowledging and agreeing to the above information. All patients must complete this form and agree to the terms before receiving any treatment or medical assistance both in person and through phone.