PATIENT�S REQUEST FOR MEDICAL SERVICES

Perhaps you have heard reports of a �malpractice crisis.� Lawsuits can be costly, time-consuming and distracting. This form is for patients requesting medical care by the [MEDICAL PRACTICE NAME], and its employees and affiliates, including but not limited to [DOCTORS� NAMES] (jointly and severally, the �Clinic�). Feel free to decline to sign this form, or see a different doctor. You may freely use our phones to call anyone for advice in filling out this form.

Are you having an emergency at this time? (write yes or no) ______ Patient�s initials: _______

If the answer is �yes�, then stop now and request emergency help immediately.

I irrevocably agree (i) to submit any and all claims against the Clinic to arbitration rather than to a judge or jury, (ii) that the Clinic may submit any claim by me to binding arbitration, and (iii) to be bound by the result even if I decline to participate:

Yes: _____ No: _____ Patient�s initials: _______

I irrevocably agree to limit any claim relating to any diagnosis, treatment or care by the Clinic to $250,000 for all non-economic damages, including pain and suffering or inconvenience:

Yes: _____ No: _____ Patient�s initials: _______

In the event I assert a claim against the Clinic and it is denied, then I agree to pay for the reasonable attorney and expert fees of the Clinic�s defense:

Yes: _____ No: _____ Patient's initials: _______

I request services from the Clinic in full agreement with and understanding of the above. I do not rely on any oral representations by anyone on staff in completing this form and am not under any pressure to sign. This form applies to all past and future services rendered by the Clinic and shall bind me and my heirs, legal representatives and assigns. Each provision shall be severable from the remainder and enforceable to the fullest extent of the law.

Patient�s signature: _______________________________ Date:________________

Patient�s name:_________________________________

A copy of this signed form was received from the patient by:

Staff member�s signature: _________________________ Date:________________

Staff member�s name: __________________________