Click on Calendar, type the year 'YYYY' and pick the month & date.
Sacramento Natural Dentistry


  First name

  Mid Initial

  Last name

Arbitration Agreement

ARTICLE 1
It is understood that all disputes, including but not limited to alleged medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, or any disputes arising out of Patient's relationship with Doctor will be determined by submission to arbitration as provided by California state law and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
ARTICLE 2
a. Parties To The Agreement The term "Patient" as used in this Agreement includes the undersigned individual, his or her spouse, children (whether born or unborn), and heirs, assigns, personal representatives, or executor of Patient's estate. The individual signing this Agreement signs it on behalf of the foregoing persons, and intends to bind each of them to arbitration to the full extend permitted by law.
The term "Doctor" as used in this Agreement includes the undersigned doctor and his professional corporation or partnership, and any employees, agents, successors-in-interest, heirs and assigns of the foregoing individuals or entities. The Doctor signing this Agreement signs it on behalf of all the foregoing individuals and entities, and intends to bind each of them to arbitration to the full extend permitted by law.
b. Treatment Covered Patient understands and agrees that any dispute of the sort described in Article 1 between Doctor and Patient will be subject to compulsory, binding arbitration.
c. Other Doctors (If Applicable) Patient understand that he or she may at times receive treatment form one or more doctors who practice jointly with the undersigned Doctor. It is understood and agreed that any dispute of the sort described in Article 1 between Patient and such doctors practicing with the undersigned Doctor will be subject to compulsory, binding arbitration.
d. Coverage of Prenatal Claims (If Applicable) Patient understands and agrees that, if Doctor treats her during pregnancy, and dispute of the sort described in Article 1 as to medical treatment rendered to or affecting the unborn child will be subject to compulsory, binding arbitration.
ARTICLE 3
a. Informal Resolution of Disputes In the event Patient feels that a problem has arisen in connection with the medical care rendered by Doctor to Patient, Patient will promptly notify Doctor so that Doctor may have the opportunity to resolve the matter. Notice may be given orally or in writing, and shall stop the running of the statute of limitations for 90 days.
b. Method of Initiating Arbitration If the dispute is not resolved by mutual agreement within 90 days of the notice required under Article 3, Subsection(a) of this Agreement, Patient may initiate arbitration by notifying Doctor to the effect and by designating an arbitrator to act on Patient's behalf. Within 20 days of receipt of such notice, Doctor will designate an arbitrator to act on Doctor's behalf. In the event that more than two parties participate, parties aligned Doctor shall select a second arbitrator. The two "party" arbitrators shall select a neutral arbitrator. The controversy shall then be submitted to the three arbitrators for a final and binding decision. Each party shall pay on-half of the costs and expenses of the arbitration, and each shall separately pay its respective counsel fees, witness fees, and expenses.
c. Applicable Law The arbitration shall be conducted pursuant to California's Uniform Arbitration Act IRCW 6.04A.010-903). Pursuant to RCW 7.04a.170, the arbitrators shall have authority to order such other discovery as they deem appropriate for a full and fair hearing of the case. A determination on the merits shall be rendered in accordance with the law and rules of the State of California.
d. Interpretation of Agreement Any controversy concerning the interpretation or application of this Agreement itself shall also be submitted to arbitration in the manner provided above.
ARTICLE 4
Revocation If you sign this Agreement and then change your mind, the law permits you to revoke the Agreement, providing you give the undersigned Doctor written notice within 30 days from signing that you want to withdraw from the Agreement. However, Doctor and Patient agree that any claim arising from medical services rendered prior to revocation shall be subject to arbitration in accordance with this Agreement.
If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

* I agree to have any and all disputes including, but not limited to, issues of medical malpractice decided by neutral arbitration and I give up my right to a jury or court trial. (See Article 1 of this contract).
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)