I am the person whose name appears on this form and all information is correct to the best of my knowledge. In addition, I understand that NYC Travel Consultant INC. is a luxury service (not a medical service or medical provider) intended to provide logistical and coordination assistance with my outpatient cosmetic surgery procedures. I understand that NYC Travel Consultant INC is not a substitute for medical care or hospitalization and, as such, I am electing to use the services of NYC Travel Consultant INC as a matter of convenience and not for reasons related to medical care. I agree that in all cases NYC Travel Consultant INC liability will be limited to the fee I have paid to NYC Travel Consultant INC for its services, regardless of the nature of the claim, and I fully waive any and all rights otherwise. I hereby acknowledge that I am of legal age and of sound mental capacity and that I make this election free from any duress or undue influence. I understand and agree that NYC Travel Consultant INC is not in any way affiliated or associated with, and does not sponsor, any of the services I may receive from my doctor or the lodging facilities I may use during travel and recovery. and NYC Travel Consultant INC does not monitor, evaluate the suitability of, supervise, or in any manner control, direct, or monitor the actions of any such parties. I understand that I am responsible for evaluating whether my doctor, the medical facilities and any lodging or recovery facilities are suitable for the services provided and all such evaluations and determinations having been made exclusively by me. I agree, on behalf of myself, any family members, my heirs, successors, and assigns, to indemnify and hold harmless NYC Travel Consultant INC and all of its owners, agents, officers, directors, employees, subsidiaries, and affiliates (each a “NYC Travel Consultant INC Indemnified Party”) from and against any and all loss, liability, damage, cost, expense (including reasonable attorneys' and expert witness’ fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission, or state of facts and/or any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I may sustain: (1) in connection with, as a result of and/or otherwise arising out of any services provided to me by NYC Travel Consultant INC.; (2) in connection with, as a result of and/or otherwise arising out of any failure of NYC Travel Consultant INC. to provide any services or care to me; (3) NYC Travel Consultant INC.’s negligence, misconduct, intentional conduct, and/or actions; and/or (4) in connection with, as a result of and/or otherwise arising out of my surgery, my outpatient recovery care, and/or my post-operative medical treatment. Further, I understand that my medical care, at all times, and in all circumstances, remains the responsibility of the surgeon who performed my surgery. I understand that only my surgeon is authorized to write prescriptions for me and to determine if outpatient recovery care is appropriate for my particular recovery needs. I understand that my surgeon is the only party with the authority to order and perform post-operative medical treatment and he or she reserves the right, alone, to order my hospitalization, if that is the level of care I require. I further understand that my surgeon is the only party authorized to determine the level of post-operative care needed following my procedure, including whether discharging me to a non-medical facility, such as home or another recovery facility booked by NYC Travel Consultant INC., is appropriate. In consideration of the foregoing, I still elect to utilize the services of NYC Travel Consultant INC.. I agree to indemnify and hold harmless NYC Travel Consultant INC. and all of its owners, agents, officers, directors, employees and affiliates from and against any and all loss, liability, damage, cost, expense (including reasonable attorneys' fees and disbursements and costs of investigation), judgment, charge, fine, interest, penalty or assessment resulting from, arising out of, or relating to, any act, omission or state of facts and any demand, action, suit, proceeding, claim, assessment, judgment or settlement or compromise, whether known or unknown, of any kind whatsoever that I may sustain in connection with the services provided to me by NYC Travel Consultant INC. or any of the foregoing.