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  • Waiver, Quitclaim and Release: For Pre-Termination of Services/Orthodontic Treatment

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    Baby Dolle Jia
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    This document is a waiver, quitclaim, and release for pre-terminating orthodontic services. The patient acknowledges that pre-terminating treatment means the objectives will not be achieved and risks explained may materialize. The patient agrees to pay half the remaining balance with no refund, and the dentist may refuse resuming treatment. The patient waives all legal action against the clinic and dentist regarding the pre-terminated treatment and agrees to hold them harmless from any claims arising from the pre-termination.

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    This document is a waiver, quitclaim, and release for pre-terminating orthodontic services. The patient acknowledges that pre-terminating treatment means the objectives will not be achieved and risks explained may materialize. The patient agrees to pay half the remaining balance with no refund, and the dentist may refuse resuming treatment. The patient waives all legal action against the clinic and dentist regarding the pre-terminated treatment and agrees to hold them harmless from any claims arising from the pre-termination.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    2K views1 page

    Waiver, Quitclaim and Release: For Pre-Termination of Services/Orthodontic Treatment

    Uploaded by

    Baby Dolle Jia
    This document is a waiver, quitclaim, and release for pre-terminating orthodontic services. The patient acknowledges that pre-terminating treatment means the objectives will not be achieved and risks explained may materialize. The patient agrees to pay half the remaining balance with no refund, and the dentist may refuse resuming treatment. The patient waives all legal action against the clinic and dentist regarding the pre-terminated treatment and agrees to hold them harmless from any claims arising from the pre-termination.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    WAIVER, QUITCLAIM AND RELEASE

    For Pre-Termination of Services/Orthodontic Treatment

    I,______________________________________________, Filipino, married/single, of legal age, and a resident of


    ___________________________________________________________, after having been duly sworn in accordance
    with law, hereby depose and state that:

    1. I have engaged the services of the Dr. ___________________________ (hereinafter referred to as “the dentist”),
    specifically to render the services more particularly described in the contract;

    2. The dentist, has fully and clearly explained to me: (i) the nature of the Services, (ii) the risks relating thereto and
    (iii) the post-treatment and/or post-operation guidelines applicable to the Services. I confirm that I fully understood
    the nature of the Services, consented to the risks involved and took full responsibility in following the prescribed post-
    treatment and/or post-operation guidelines in order to avoid complications;

    3. In my decision to pre-terminate the Services and stop receiving orthodontic treatment from the dentist, I accept and
    acknowledge that:

    a. the objective for which the Services were rendered will not be achieved;
    b. the risks explained to me, as well as other possible complications (post treatment and/or post-operation),
    can materialize;
    c. there shall be no refund of fees and need to pay half of the remaining balance;
    d. the dentist has the right to refuse resumption of pre-terminated Services/orthodontic treatment; and
    e. no dental/orthodontic records shall be released by the dentist to me or to my authorized representative/s.

    4. In connection herewith, I hereby waive any right to pursue any and all forms of legal action which includes
    administrative, civil, or criminal cases against the Clinic, dentist/s, personnel, and staffs. I have not authorized and
    will not authorize any party or person to pursue or file such legal action/s on my behalf before any court of law or any
    government agency regarding any matter incidental to, arising out of, or in connection with services/orthodontic
    treatment which I have pre-terminated; and

    5. Lastly, I hereby agree to (i) hold the Clinic, dentists/, and staffs free and harmless from any and all claims, actions,
    and liabilities that may be made against the dentist arising from or in connection with the pre-termination of the
    Services/orthodontic treatment and (ii) indemnify the dentist, on demand, from any such claim, action, and liability
    whatsoever which may arise or result from this pre-termination.

    IN WITNESS WHEREOF, I have hereunto affixed my signature this ________day of ___________, 20___ in the
    City of _________________________________________.

    ____________________________________
    Patient’s Signature over Printed Name

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