Inova BackNET Waiver & Registration

Inova BackNET - Waiver and Release Agreement

Please Read: Confirmation of acceptance of the Waiver and Release Agreement is required in
order to participate in Inova HealthNET.

1. I understand that the information provided to me through Inova HealthNET (of which Inova BackNET is a
member program) is for informational and educational purposes only, and it is neither intended nor implied to
be a substitute for professional medical advice. I understand that I should seek the advice of my physician
with any questions I may have regarding any personal medical condition. I assume any and all risks
associated with participating in Inova HealthNET, with or without prior consultation with my physician.

2. I understand that I may discontinue participation in Inova HealthNET at any time.

3. All information related to my participation in Inova HealthNET will be treated in a strictly confidential and
private manner at all times. Data from all program participants are reviewed, evaluated and reported in order
to monitor and improve program effectiveness. I understand that reports will be constructed so that all
individuals will be protected from any identification or disclosure.

4. I understand that Inova Health System, by making Inova HealthNET available, is not undertaking any
responsibility regarding my medical condition(s). If my medical condition should change or require medical
attention, I will immediately consult with my physician.

5. I hereby release and hold harmless Inova Health Systems, their respective directors, trustees, officers,
parents, subsidiaries, affiliates, employees and agents from and against any and all demands, damages,
losses, costs, expenses, obligations, liabilities, claims, actions, and causes of action (whether any of which
is groundless or otherwise) of any nature whatsoever (including, without limitations, reasonable attorney's
fees and court costs) by reason of or resulting, in any way, from any and all acts, accidents, events,
occurrences, omissions and the like related to, or arising out of , directly or indirectly, my participation in
Inova HealthNET.

6. Should a provision of this agreement or portion thereof be found invalid or void as against public policy by
any court of competent jurisdiction, the remainder of this agreement shall nonetheless remain in full force and
effect.

7. By checking the box on the registration form, I am acknowledging that I understand and accept the terms
of this agreement.