Brace Purchase Agreement/Disclaimer

Date*
MM slash DD slash YYYY
Name*
First Last
*
- I understand that by signing this agreement I am purchasing this brace.
*
- I also understand that there is a no return & no refund policy for this device.
*
- I also understand that there is no guarantee that this device will reduce or stabilize my (my child’s) Scoliosis or Kyphosis.
I have read this agreement and understand the previous statements.
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Patient Name*
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Patient Signature*
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Patient’s legal guardian
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Patient’s legal guardian Signature
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