Contract for the provision of medical services nr. Concluded on the.2014 in Jelenia Gra between: KCM Clinic S.A.

ul Bankowa 5-7 in Jelenia Gra, established on the basis of registration number KRS Nr: 00000396826; REGON: 021685332; NIP: 611-272-20-32 hereinafter referred to as the Healthcare Provider, represented by: Monika Mikulicz-Pasler Head of the Board and Patient: __________________________________ Address:__________________________________ 1 1.Subject of the contract is the payable execution of medical services for the Patient (name) _________________________________________ Medical service: ____________________________ Signature (Doctor): _________________________

5 The amount mentioned in 4. Point 1 should be paid after signing the contract and before the surgery/treatment which is mentioned in 1 Point 1. The payment mentioned in Point 1 should be performed on the bank account of the Healthcare Provider or Clinic: SWIFT ALBPPLPW

IBAN Account Number: PL 32 2490 0005 0000 4520 5253 6195 (PLN) PL 80 2490 0005 0000 4600 2428 5846 (USD) PL 84 2490 0005 0000 4600 6111 9390 (EUR) Or in the reception of the Healthcare Provider 8:00am. 19.35 pm. 3. The confirmation of the payment has to be present at the admission to the Clinic. 6 1.Both sides have the right to cancel the contract minimum 3 days before the surgery/treatment (mentioned in 1 Point 1). 2. The contract can be cancelled at any time with the consent of both parties.

Before the operation (mentioned in 1) the Patient is obliged to: a) Pay the Healthcare Provider for the medical services. (Amount specified in 4. Point 1 of the contract) Prepare for the surgery (according to the recommendations of the doctor), provide the Clinic with fully and solid health information and passed diseases.

3.For damages in connection with the dissolution of the contract as specified in Point 1, the Healthcare Provider is entitled to compensation of the amount which actually incurred and the extra costs associated with readiness for work and administrative costs based on a calculation. 7 Matters which are not covered by the agreement are in force of: the provisions of the Civil Code, the Law on Healthcare and other applicable law. 8 Disputes arising in the course of performance of the contract shall be settled by the court competent for the Healthcare Provider. 9 1. This contract is claimed to be valid in writing. Changes and additions to the contract require a written form to be valid. This contact is created in 2 copies, one for each party.

b)

2.The Healthcare Provider is obliged to carry out the surgery/treatment with the highest precision and according to: The laws and regulations of Poland Indications of current medical knowledge Professional ethics rules

3. The Healthcare Provider is not liable for unpredictable post-operative effects of the treatment/surgery. 3 Foreseen date of the surgery/treatment: ______________________________________________ 4 1.The Patient covenants to pay the Healthcare Provider the amount________________________ in words)__________________________________ 2. The amount which is contained in point 1, can increase in case of additional, unforeseen and necessary medical services.

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Healthcare Provider (signature) Patient (Signature)

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