Document Downloads & Binding Arbitration Information

INFORMED CONSENT AGREEMENT

(INSERT NAME OF PRACTICE)

I, the undersigned, have watched the informed consent agreement video relative to my procedure to be performed today. I understand the explanation of risks given to me both by this video and in answer to my solicited questions. Alternatives have been explained to me, but I choose the treatment now to be performed as is noted on my treatment plan.

I further agree that any dispute about the reasonableness or computation of the fees, or any claim of negligent or intentional acts or omissions in the rendering of professional services, either in this specific instance or in any other treatment rendered by staff in this office, shall be submitted to binding arbitration to the American Arbitration Association, National Futures Association or internet-ARBitration.  It is understood by both doctors and patient that by agreeing to submit all claims or assertions that either patient or doctor may have against the other arising out of this agreement patient and doctors have given up their right to a jury or a court trial.

Procedure  _________________________Account #___________________

Print name ______________________________________Date__________

Signature   ____________________________________________________

Signature  _____________________________________________________
                  (Parent or Legal Guardian for children under age 18)

 

Witnessed ______________________________________Date___________