Dental Services Waiver of
This document can be used by a dentist to obtain a waiver of liability from patients.
Dentists can merely fill out their information and the waiver will be ready to be
distributed to incoming patients who will then read, sign, and date the waiver. Make sure
to check your state’s laws to determine whether waivers will be upheld and enforceable.
This waiver is ideal for small businesses that offer dental services and want to obtain a
waiver of liability from patients.
WAIVER OF LIABILITY
THIS WAIVER OF LIABILITY (hereinafter referred to as the “Waiver”) is hereby made and
entered into by and between _________________________ [Instructions: Insert the Dentist’s
name] (hereinafter referred to as the “Dentist”), of
_______________________________________ [Instructions: Insert the Dentist’s address]
and the Patient (hereinafter referred to as the “Patient”).
WHEREAS, Dentist and Patient entered into a dental services agreement (hereinafter referred to
as the “Agreement”) with respect to Dentist’s providing of dental care to Patient; and
WHEREAS, the parties agree that the terms of this Waiver are integral to Dentist providing
dental services pursuant to the Agreement, and desire to clarify the each party’s rights and
remedies with respect to the Agreement with the terms of this Waiver.
NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth
below, it is hereby covenanted and agreed by the parties as follows:
1. LIMITATION OF LIABILITY
The parties expressly agree that Dentist shall not be liable for any direct, indirect, incidental,
special or consequential damages, resulting from Dentist’s performance of the dental services
pursuant to the Agreement. The foregoing limitation of liability shall include any claims of
dental malpractice (i.e., whether any dental services rendered pursuant to the Agreement were
unnecessary or unauthorized or were improperly, negligently or incompetently rendered).
Dentist shall not be liable for the any costs incurred by Patient as a result of the dental services
provided pursuant to the Agreement, including without limitation any subsequent dental costs.
Patient hereby expressly waives any right to direct, indirect, incidental, special or consequential
damages for claims disputes and other matters arising out of or relating to the Agreement and/or
Dentist’s dental services. The parties expressly agree that Dentist’s maximum liability to Patient
arising from the Agreement shall be limited to the sums paid by Patient to Dentist.
2. APPLICABILITY TO CLAIMS AND ACTIONS
This Waiver applies to any legal claim or civil action in connection with the dental services
provided pursuant to the Agreement, including, but not limited to, disputes as to dental
malpractice, against Dentist, Dentist’s practice, the hospital or facility where Dentist’s practice is
located, and/or Dentist’s employees.
3. RESCISSION OF WAIVER
The execution of this Waiver is not a pre-condition to the furnishing of dental services by
Dentist. This Waiver may be rescinded by written notice from the Patient or Patient’s
representative to the Dentist within __________ (___) [Instructions: Insert number of days]
days of Patient’s execution hereof.
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a. This Waiver constitutes the entire agreement between the parties hereto with
respect to the specific subject matter hereof and supersedes all prior agreements or
understandings of any kind with respect to the specific subject matter hereof.
b. In the event that any provision or part of this Waiver shall be deemed void or
invalid by a court of competent jurisdiction, the remaining provisions or parts shall be and
remain in full force and effect.
c. Any and all additions, deletions, or modification to this Waiver must be in writing
and signed by the parties or it shall have no effect and shall be void.
d. This Waiver is binding upon and shall inure to the benefit of the respective
successors, licensees and/or assigns of the parties hereto.
e. This Waiver shall be governed in accordance with the laws of the State of
_____________________ [Instructions: Insert the state’s laws that will govern this waiver]
applicable to agreements to be wholly performed therein, without giving effect to its laws
governing conflict of laws.
BY SIGNING THIS WAIVER YOU ARE AGREEING TO WAIVE ALL CLAIMS
RELATING TO DENTIST’S DENTAL SERVICES, INCLUDING, WITHOUT LIMITATION
ANY CLAIM OF DENTAL MALPRACTICE, AND YOU ARE GIVING UP YOUR RIGHT
TO A JURY OR COURT TRIAL. SEE PARAGRAPH 1 OF THIS WAIVER.
I hereby agree to release the Dentist from any and all liability that may arise from the dental
Patient’s Name: _________________________________
Patient’s Signature: _______________________________
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