Service Agreement Form

Dr.Ethix's Wellnezzone Home Nursing Services
No:111, D Block, 1st main road, Annanagar East
Chennai - 600 102, T.N., India,
Contact : 95000 73479 / 95977 10333
Website : www.welnez.org

Service Agreement

Patient / Client Name

Please enter a name.

Age

Please enter age.

Address

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Service Start Date

Please select a service date.

Relationship (if signing on behalf)

Registration Fee ($)

Please enter registration fee.

Tariff Amount ($)

Please enter tariff amount.

Terms and Conditions

I acknowledge that I have received, read, and understood the terms of service provided to me.

You must agree before submitting.

I agree to the tariff amount and registration fee specified above, and I understand the cancellation policy.

You must agree before submitting.

Upload Signature

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Client / Representative Signature

[Company Stamp/Signature]

Company Representative

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