DENTAL SERVICES AGAREEMENT

DENTAL SERVICES AGAREEMENT

Carmella Mashian, “Doctor”, and the undersigned patient ("Patient”) have agreed as follows:

ARTICLE 1. IT IS UNDERSTOOD THAT ANY DISPUTE AS TO DENTAL MALPRACTICE, THAT IS AS T0 WHETHER ANY DENTAL SERVICES RENDERED UNDER THIS•CONTRACT WERE UNNECCESSARY OR UNAUTHORIZES OR WERE IMPROPERLY, NEGLGENTLY OR INCOMPELETY RENDERED, WIILL BE DETERMINED BY SUBMISSION TO ARBITRATION AS PROVIOED BY CAUFORNIA LAW, AND NOT BY A LAWSUIT OR RESORT TO COURT PROCESS EXCEPT AS CONTRACT, BY ENTERING INTO, ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE' USE OF ARBITRATION.

ARTICLE 2. In the event of any claim, demand, controversy or dispute the essential nature of which involves personal injury, malpractice or any tort by Patient, his/her dependents, whether or not minor, heirs at law or personal representative against Doctor or any of Doctor’s officers, directors, shareholders, agents, representatives, employees, successors in interest, assigns or associates agreeing in writing to be bound by arbitration provisions of this agreement (“affiliates”). THE SOLE METHOD FOR RESOLVING SUGH DISPUTE SHALL BE BY BINDING ARBITRATION ASSOCIATION in accordance with the Commercial Arbitration Rules of American Arbitration Association. The parties hereby agree that they shall submit their controversy to an Arbitrator who is a dentist licensed in California. Such Arbitrator shall be acceptable to both parties. In the event that the parties cannot agree upon a sole Arbitrator, each party shall pick an Arbitrator who is a dentist in California and the two Arbitrators shall pick a third Association. Not withstanding the forgoing, two additional Arbitrators who are dentists may be added by the parties by agreement in writing to create an arbitration panel of three. It is agreed that all parties relevant to a full and complete settlement of any dispute subject to this agreement may be intervened or joined.

ARTICLE 3. The prevailing party in any Arbitration pursuant to this agreement shall be awarded all costs, including reasonable attorneys' fees and the arbitrators' fees in prosecuting or defending the calm In arbitration, but not to exceed $5.000 in amount. Furthermore, if any action is undertaken to set aside or otherwise attack the binding Arbitration award, the loosing party in the court action shall bear all the prevailing party's costs, including reasonable attorneys’ fees.

ARTICLE 4. Any party initiating arbitration under this agreement shall file with his petition a bond or cash surely in an amount equal to Five Hundred Dollars ($500) which shall provide security for attorneys’ fees and costs in the event that the moving party shall not prevail.

ARTICLE 5. This agreement shall govern all future services rendered to Patient by Doctor and Doctor’s Affiliates and associates. Execution of this agreement is a precondition to the furnishing of services by Doctor, but this agreement may be rescinded by written notice by either party within thirty days signature. After those thirty days, this agreement may be changed or revoked only by a writ ten revocation signed by both parties.

ARTICLE 6. I understand that each Dentist is an individual Practitioner and is individually responsible for the dental care rendered to Patient.

ARTICLE 7. Doctor hereby agrees to render dental care and service to Patient. Patient agrees to pay Doctor promptly upon the rendering a bill at the currently prevailing rates, or to cooperate with Doctor in obtaining payment from third party payers.

ARTICLE 8. Except for the fact that Doctor has indicated professional services will not be rendered to Patient unless this agree¬ment is executed, Doctor has made no other representations or statements, oral or written to induce Patient to execute this agreement.

ARTICLE 9, In the event that any provision of this agreement shall be void or unenforceable for any reason whatsoever, then such provision shall be stricken and of no force and effect. The remaining provisions of this agreement, however, California law shall continue in full force and effect, and to the extent required shall be modified to preserve their validity. This agreement shall be governed by.
THIS IS A BINDING LEGAL DOCUMENT WHICH MAY HAVE AN IMPORTANT EFFECT ON YOUR LEGAL RIGHTS. CONSULT YOUR ATTORNEY ON ANY OUESTIONS YOU MAY HAVE.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Date:

We promise to provide our patients with the ultimate care in Cosmetic Dentistry. This includes delivering the highest quality of technical care and treating our patients with respect, courtesy and compassion.

All regular and PPO insurances are accepted except Medical and HMO.