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.
Dental Services Waiver of Liability 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. © Copyright 2014 Docstoc Inc. registered document proprietary, copy not 2 4. MISCELLANEOUS 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. 5. NOTICE 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 services rendered. Patient’s Name: _________________________________ Patient’s Signature: _______________________________ Date: ___________________________________ © Copyright 2014 Docstoc Inc. registered document proprietary, copy not 3
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