RELEASE FROM CLAIMS FOR DAMAGES AGAINST HOSPITAL-GENERAL

I, _____________________ (Name), of ____________________________ (Address), for the sole consideration of $____________________ paid to me, receipt of which is acknowledged, release, acquit, and discharge __________________________________ (Name of Hospital) of ___________________________________________ (Address), referred to as the hospital, and any and all other persons, firms, partnerships, and corporations that are or might be claimed to be liable to me from all claims and demands of whatever nature, actions and causes of action, damages, costs, loss of services, expenses and compensation on account of or in any way growing out of personal injuries and property damage having already resulted or to result at any time in the future, whether or not they are in the contemplation of the parties at the present time and whether or not they arise following the execution of this release, as the result of and by reason of treatment rendered to me at the hospital commencing on _________,19___ and thereafter, specifically including but not limited to __________________________ (Full description of treatment received). 

I, for myself and my heirs, administrators, executors and assigns, covenant with the hospital and any and all other persons, firms, partnerships, and corporations that are or might be claimed to be liable to me as a result of the accident, requiring the treatment mentioned above, to indemnify any and all of them from all claims and demands or damages, costs, loss of services, expenses and compensation on account of, or in any way growing out of the accident and its results, past, present, or future, both to persons or property.

This release expresses a full and complete settlement of a liability claimed and denied, and, regardless of the adequacy of the compensation, is intended to avoid litigation. There is absolutely no agreement on the part of any or all of the persons, firms, partnerships, or corporations released by this agreement to make any payment or to do any act or thing other than is expressly stated and clearly agreed to in the agreement. 

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