ACKNOWLEDGEMENT & RELEASE FORM
The recipient has asked 98 Alive Pty Ltd (the Company) to supply him/her with a product known as M.A.C. (Melaleuca Alternifolia Concentrate) being trialled by the company for the treatment of the Recipient and in consideration for the Company supplying the Product, the Recipient has provided this deed of acknowledgement and release to the Company.
NOW THIS DEED WITNESSES AS FOLLOWS:
1 The Recipient acknowledges that:
I the Product is still being trialled and is in the early stages of its development for use in humans. (II) none of the Company, its employees, advisers and other suppliers of the Product make any representation or warranty as to:
a the effectiveness, side effects, compatibility or otherwise regarding the Product’ or
b the effectiveness, side effects, or compatibility or otherwise with other medications or substances being taken by the Recipient; or
c the reliability or completeness of Information concerning the use and results of
the use of the Product in humans; and
II no information concerning the Product may be relied upon as a promise or representation contrary to this acknowledgement concerning the Product.
2 The Recipient agrees to strictly adhere to directions given as to the appropriate Dosage and use of the Product including without limitation, agreement to take the full course of the Product as prescribed unless otherwise directed by a qualified medical practitioner.
3 By accepting the Product, the Recipient acknowledges that he or she is Participating in a trial of the product and agrees to co-operate with the Company in monitoring and reporting of the results associated with the trial of the product. The recipient hereby authorises the Company to publish results concerning the trial in such publications as the Company sees fit (on the basis that the Recipient’s name is not mentioned unless the Recipient specifically authorised such disclosure)
4. Except to the extent prohibited by law, the Company and its related bodies Corporate, its officers, employees and representatives disclaim all liability that may otherwise arise due to the use of the Product and any information that may have been given or representations made concerning the Product being inaccurate or incomplete or the Product not achieving the results discussed at the time of its prescription or achieving results other than those discussed at the time of its prescription.
5. In consideration of the Company supplying the Product to the Recipient, the Recipient agrees to release and forever discharge the Company, its officers, employees and/or representatives from any and all liability, actions, claims suits, demands, causes of action and costs howsoever arising out of or in connection with the Recipient’s use of the Product and its effects, save to the extent such liability cannot be limited under the laws of the Commonwealth of Australia or the state or territory governed by this Deed. The recipient consents and acknowledges the right if the Company to rely on the contents of this Deed to defend any claim that may be made by the Recipient against the Company, its officers, employees and/or representatives.
6. The Recipient warrant to the Company that he or she has:
(I) read and understood the contents of this Deed, or alternatively that he or she has sought independent legal advice in relation to this Deed before executing same; and
(II) disclosed to the Company or its representatives all relevant details of his or her medical history and medication currently being taken, prior to and in connection with his or her request to use the Product; and
(III) Advise their medical practitioner of the use if this Product and sought their advice in relation to the same.
7. The Deed shall be governed by the laws of the State of Queensland.
EXECUTED AS A DEED
SIGNED SEALED AND DELIVERED BY: