By signing this agreement, you are:
Waiving your statutory right to a jury trial, and
Agreeing to arbitrate all claims arising out of or
Related to your orthodontic care and treatment.
The term “Doctors” refers to Drs (insert the name of every owner or shareholder) and their corporate owners, agents, contractors, employees, administrators, and licensees, and all affiliates thereof. The term “Patient” means and includes any legal representative, family member, agent, executor, guardian, power of attorney, or any other person acting for or on behalf of the Patient.
Agreement to arbitrate
The Patient agrees that all claims or controversies between the Doctors and the Patient arising out of or in any way relating to orthodontic services rendered to the Patient by the Doctors, including disputes regarding interpretation of this agreement, whether arising out of state or federal law, and whether based upon statutory duties, breach of contract, tort theories, or other legal theories, shall be submitted to final and binding arbitration. It is understood that any dispute as to dental malpractice, that is, whether any dental services rendered to the Patient by the Doctors were unnecessary or unauthorized, or were improperly, negligently, or incompetently rendered, as well as any claims for personal injury, loss of consortium, or any other injury or loss incurred, arising out of or in any way relating to the diagnosis, treatment, or care of the Patient, will be determined by submission to arbitration.
Waiver of the right to a jury trial
Both parties, by signing this contract, agree to give up their constitutional right to have any dispute between them decided in a court of law before a judge and jury. Instead, the parties are accepting the use of binding arbitration. The resolution of claims covered by this agreement will be determined by a neutral panel of arbitrators and not a judge or jury. The arbitrator’s award shall be final and binding without the right of appeal except as may be provided under the laws of the state of (insert state name).
Except as herein provided, the arbitration shall be conducted and governed by any currently existing statutory provisions governing or pertaining to arbitration in the state of (insert state name). In addition, the arbitrator(s) shall apply the laws of (insert state name) governing or pertaining to dental malpractice including but not limited to the standards of care for orthodontic providers, the use of expert witnesses, the laws of evidence, and the applicable statute of limitations.
Presuit notice demands
Before commencing any action under this agreement, the Patient must comply with any presuit notice, investigation, or requirements as mandated by _______________ state law. Any demand for arbitration shall be made in writing and be submitted to the other party to this agreement via certified mail, return receipt requested. If either party to this agreement refuses to go forward with arbitration, the party compelling arbitration reserves the right to proceed with arbitration as set forth in this agreement, without the participation of the party opposing arbitration, or despite his or her absence at the arbitration hearing.
Venue, fees, and costs
The arbitration proceedings shall take place in __________________ County, state of _________________, and be administered by, and under the rules of, the American Arbitration Association. (At this point, you can elect to have 1 or 3 arbitrators. If 1, he or she is mutually agreed upon. If 3, each side chooses 1, and the 2 arbitrators choose the third.) The arbitrator’s fees and costs associated with the arbitration shall be divided equally between the parties. The parties shall bear their own attorney’s fees and costs and hereby expressly waive any statutory right to recover attorney’s fees or costs from the opposing party.
One proceeding binding on all parties
All claims based upon the same occurrence, incident, or care rendered shall be arbitrated in 1 proceeding. It is the intention of the parties that this agreement shall bind all parties whose claims may arise out of or relate to the treatment or services provided by the Doctors as well as to the Patient, the Patient’s estate, spouse, heirs, or children at the time of the occurrence giving rise to the claim. In the case of a pregnant woman, the term “Patient” herein shall mean both the mother and her expected child or children. By signing this agreement, the parties consent to the participation in this arbitration of any person or entity that would otherwise be a proper additional party in any court action.
This agreement constitutes the entire agreement between the parties regarding the subject matter of this agreement and supersedes any prior understandings, agreements, or representations by or among the parties, written or oral.
If any provision of this agreement is declared invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
It is understood by the Patient that: (1) he or she is not required to use the Doctors for his or her orthodontic needs, and (2) that there are other orthodontists or dentists who provide orthodontic services within the locale of doctor’s office(s) who are qualified to perform orthodontic treatment.
Each party shall have 3 business days from the execution of this agreement to cancel the agreement by notifying the other party in writing, by certified mail, return receipt requested, of its desire to cancel this agreement. It is understood by the Patient, that if a doctor-patient relationship has already begun and the Patient decides not to agree to the provisions herein, then the Doctors have the right to withdraw from rendering further treatment to the Patient as long as withdrawing the services will not unduly affect the health of the Patient.
By signing this agreement, I acknowledge that I have:
Carefully read and understand its terms
Voluntarily entered into this agreement
Had the opportunity to consult with an attorney
Agreed to be bound by its terms and conditions.
|(Name of practice or doctor)||Patient: ___________________|
Patient or legal representative
|Date: ___________________||Date: _____________________|
Description of legal authority