| This agreement, made and entered into this day ______________________ by and between Hargitt House Enuresis Treatment Center, Inc. P.O. Box 130342, The Woodlands, TX 77393-0342, hereinafter referred to as H.H.E.T.C. | |||||||||
| And | |||||||||
| Name:
_____________________________________________________________
Phone: _____________________________________________________________ Address: ___________________________________________________________ City/State/Zip: _______________________________________________________ Email: _____________________________________________________________ |
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| Hereinafter referred to as "Family", is as follows: | |||||||||
| H.H.E.T.C. agrees to provide and make available to the "Family" its system of education, motivation and training consisting in part of this provision by H.H.E.T.C. of counseling and related educational and motivational literature. | |||||||||
| The "Family" hereby undertakes to keep all information about the Treatment Program confidential and not to disclose the same to any third party or to use same on anyone other than the enuretic, either during the term of this agreement or thereafter, without the express written consent of H.H.E.T.C. The "Family" agrees to fully and faithfully use the equipment and guidance provided by H.H.E.T.C. | |||||||||
| Total fee for treatment: $550.00 United States $650.00 International | |||||||||
| We accept personal checks or payment through our website at www.hargitthousefoundation.com via Paypal. | |||||||||
| Given the personal nature of the subject matter of this Agreement, H.H.E.T.C. represents that it will keep and hold the "Family" and the enuretic confidential and shall not disclose such identity to any person, for any purpose, unless otherwise agreed in writing by the "Family". | |||||||||
| The "Family" shall comply with the terms of this Agreement, if enuretic should suffer a relapse of his/her nocturnal enuretic problem within a period of one full year after bedwetting has ceased for a period of twenty-one (21) consecutive nights, H.H.E.T.C. will provide and address the enuretic’s problem again with no additional obligation. | |||||||||
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| HARGITT HOUSE ENURESIS TREATMENT CENTER, INC. | |||||||||
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Return completed form to: |
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HARGITT HOUSE ENURESIS TREATMENT CENTER,
INC. |
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If you have any questions or concerns, please send us an email at info@hargitthousefoundation.com or by visiting the website at www.hargitthousefoundation.com. |