DISCLOSURE OF CONFLICT OF INTEREST

I acknowledge that JASE Medical and its relevant physician-owners have disclosed to me the existence of a potential or actual conflict of interest, on the part of the physician-owner, arising out of the physician-owner’s economic and ownership interest in JASE Medical.  I understand that this conflict of interest may compromise the independent professional judgment and recommendations of the physician-owner as the same relate to me, my treatment, and the issuing of any prescriptions on my behalf.