The Children’s Surgery National Applied Research Hospital, represented by the Director Drozdovski K.V., acting on the basis of the Charter, hereinafter referred to as the “Executor”, on the one hand, and the citizen  ____________________________________________________, passport _________ issued ____________________________, acting on the basis of his own will, hereinafter referred to as the “Customer” acting in the interests of the child ___________________________ of the birth, hereinafter referred to as the “Patient”, on the other hand, have concluded the present agreement as follows:

  1. The Subject of the Agreement

1.1. The Customer instructs, and the Executor commits to provide the Customer, according to the application and on a paid basis, with medical services (due to medical necessity and patient informed consent) of a certain volume and quality, at the cost of the current price list on the basis of the cost negotiation specification-protocol (Appendix No. 1 to the Agreement), which is an integral part of the Agreement.

1.2. The Customer undertakes to pay for medical services in accordance with the Agreement.

1.3. The Executor appoints independently the time and priority of appointment, determines the need and timing of hospitalization, determines the scope and nature of research and treatment.

  1. Obligations and rights of the Executor

2.1. The Executor shall:

2.1.1. get acquaint the Customer with the current price list for paid medical services;

2.1.2. provide the compliance of the paid medical services rendered to the Customer with the requirements established by the legislation;

2.1.3. ensure timely consideration of claims from the Customer;

2.1.4. control the quality of paid medical services within the limits of the official duties of the responsible persons of the Executor.

2.2. The Executor has the right:

2.2.1. in case of emergency, to determine independently the scope and nature of research, manipulation, surgical interventions necessary for diagnosis, examination and medical care, including those not provided for in the Agreement.

  1. Obligations and Rights of the Customer

3.1. The Customer is obliged to:

3.1.1. study the full information on the forthcoming provision of medical services and their consequences;

3.1.2. pay timely and fully for paid medical services provided in accordance with the cost negotiation specification-protocol  and the certificate of acceptance of the rendered services ;

3.1.3. provide the Executor with the necessary documents and information for the provision of services (information on the state of health, previous diseases, known allergic reactions, etc.), which may affect the medical services;

3.1.4. follow the rules of internal regulations, admitted by the Executor;

3.1.5. timely inform the Executor about the circumstances that may affect the performance of the Agreement;

3.1.6. provide the necessary conditions for proper provision of services by the representatives of the Executor.

3.2. The Customer has the right to:

3.2.1. receive information about the medical service;

3.2.2. require a special permit (license);

3.2.3. refuse to receive the service prior to its commencement and receive the prepayment with reimbursement of actual costs to the Executor;

3.2.4. submit claims for compensation for actual damage caused by non-performance or improper performance of the terms of the Agreement, compensation for damage in case of harm to life or health, compensation for causing moral damage in accordance with the clause 5 of the Agreement.

  1. Cost and order of payments

4.1. At the time of signing the Agreement, the estimated cost of paid medical services is ______and it is a prepayment.

4.2. The Customer makes payment under the Agreement by transferring money to the Executor’s settlement account within one banking day from the date of signing the Agreement. Payment is considered to be made upon presentation of a document confirming the payment.

4.3. All costs associated with the transfer of money to the settlement account of the Executor shall be borne by the Customer.

4.4. The basis for confirming the fact of providing paid medical services is the act of acceptance of the rendered services. The Customer is obliged to accept and sign the acceptance certificate of the  rendered services no later than one calendar day from the moment of their termination.

4.5. The certificate of acceptance of the  rendered services (Appendix No. 2 to the Agreement) is to be signed by both parties and is an integral part of the Agreement on the basis of which the final cost of the rendered medical services is calculated.

4.6. With a decrease in the volume of medical services, the Executor is obliged to refund the money to the Customer upon a written application of the Customer within 5 banking days from the date of receipt of the application.

4.7. On the day of completion of paid medical services (discharge day), the Сustomer makes a final settlement for paid services in Belarusian rubles.

4.8. The cost of paid medical services is determined by the price list valid for the date of the Agreement.

4.9. For the delay in payments provided for in the Agreement, the Executor has the right to demand, and the Customer is obliged to pay a penalty at a rate of 0.5% off the amount due for payment, for each day of delay.

  1. Special conditions and procedure for resolving disputes

5.1. The amount of the Agreement is determined on the basis of full payment for the cost of medical services rendered in accordance with the certificate of acceptance of  rendered services on the day of the Patient’s discharge.

5.2. The Customer is informed about the possibility of treatment of the disease at the place of residence.

5.3. The Customer is informed of the diagnosis, the complexity of the research, the operation and conservative therapy due to the severity of the disease, in connection with which complications are possible, up to a lethal outcome.

5.4. The Customer agrees to conduct the examination, conservative treatment and the operation.

5.5. The Parties shall take the necessary measures to ensure that any disputes, disagreements or claims concerning the Agreement are settled by mutual consent.

5.6. The rights and obligations of the Parties under the Agreement are governed by the law of the Republic of Belarus, the Parties agree to submit to the jurisdiction of the court of the Republic of Belarus.

5.7. In case the Parties do not reach an agreement through mutual negotiations and claims, the disagreements shall be subject to judicial review at the location of the Executor in accordance with the legislation of the Republic of Belarus.

  1. Force majeure

6.1. The Parties are released from the responsibility for partial or complete non-fulfillment or improper performance of obligations under the Agreement, if this failure is a consequence of force majeure circumstances.

6.2. If there is a force majeure circumstance affecting the performance of obligations under the Agreement, the Party experiencing the influence shall notify the other Party within 14 working days after the occurrence of force majeure circumstances. The Parties must make every possible effort to mitigate the consequences of force majeure after the consultation.

6.3. If force-majeure circumstances exist for 60 calendar days and at the same time the fulfillment of the Agreement within the prescribed period becomes impossible, either Party has the right to terminate the Agreement by notifying the other Party in writing.

  1. Responsibility of the Parties

7.1. The Customer is responsible for providing the necessary conditions for the provision of services under the Agreement by the representatives of the Executor, as well as for the timely payment provided for by the Agreement.

7.2. In case the Customer provides inaccurate information under the Agreement necessary for making a decision on treatment, failure to comply with the recommendations of the Executor’s specialists, the Executor shall not be liable for the final result of the provided medical services.

7.3. The Executor is responsible for the quality of service delivery.

7.4. In other cases, not stipulated in this chapter, the Parties bear responsibility in accordance with the legislation of the Republic of Belarus.

  1. Terms of the Agreement

8.1. The Agreement is valid from the moment of signing and is valid until the Parties fully fulfill their obligations.

8.2. The Agreement may be terminated by mutual consent only prior to the commencement of treatment, and the Customer pays only thec for the  rendered services.

8.3. The present Agreement is made in two copies having equal legal force, one copy is kept by the Executor, the second copy is kept by the Customer.

9. Legal addresses of the Parties