Patient's First Name: *

 
Patient's Last Name: *

 
Patient's Phone Number: *

 
How did you hear about us? *

 
Application submitted by: *

Patient, relative, friend...
 
The patient is a woman, actively receiving treatment for cancer *

     
 
Terms & Conditions *

Patient Release of Liability In consideration of the opportunity to participate in Miefy's free benevolent home cleaning program for cancer patients, I, and my heirs, successors and assigns, hereby agree and represent as follows:  I understand that Miefy cleaning agrees to perform a general clean only and do pay their employees to perform this service free of charge to me. I am 18 years of age or older and legally competent to enter into this binding legal contract. I understand that participation in Miefy’s benevolent home cleaning program is strictly voluntary and I freely choose to participate. I have completely read and understood this Patient Release of Liability. I am submitting this release and waiver of liability voluntarily and of my own free will. I agree to be bound by the terms of it.
     
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