[Physician’s Letterhead]
PATIENT CONSENT AND REQUEST FOR CARE
Dr. [physician’s name] feels that arbitration is a more cost-affordable way to resolve any disputes. In arbitration there is no judge or jury, and judgments are made by one or more independent decision-makers pursuant to the Federal Arbitration Act.
We ask patients to consider completing this form. You may decline to do so, and you may choose to see another physician. You may use our telephone to call anyone for advice about this form before completing it. If you choose to complete this form, please initial your answers below:
I am not having any kind of emergency at this time:________
If you are having any kind of emergency now, then do not complete this form.
I agree that [physician’s name] and/or [physician’s medical practice name] may submit any claim asserted by me to exclusive, binding arbitration under the rules of the American Arbitration Association pursuant to the Federal Arbitration Act, without trial before a judge or jury, and I agree to be bound by that arbitration even if I decline to participate:
Yes:______ No:________
I agree to limit any claim relating to any diagnosis, treatment or care by [physician’s name] and/or [physician’s medical practice name] to $250,000 for all non-economic damages, including pain and suffering, or inconvenience:
Yes:______ No:________
In the event I assert a claim against [physician’s name] and/or [physician’s medical practice name] and it is denied, then I agree to pay for the reasonable attorneys’ and expert fees of the defense:
Yes:______ No:________
I am not relying on any advice or oral representations by, or relationship with, anyone in this office in completing this form. I request to be a patient of [physician’s name and the name of his medical practice] in full agreement with and understanding of the above, and this form applies to all past and future services rendered to me by them.
Patient’s Signature: ______________________
Patient’s Printed Name: ___________________ Date: __________
A copy of this signed form was received from the patient by:
Staff Member’s Signature: ______________________
Staff Member’s Printed Name: ___________________ Date: __________
