Agreement to Arbitrate. It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Georgia/Tennessee law and not by a lawsuit or resort to court process of any form, except as Georgia/Tennesse law provides for judicial review of arbitration proceedings. Both parties to this contract, evidenced by patient’s signature below and HydraDrip acceptance of such signature, are voluntarily waiving their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration.
All Claims Must be Arbitrated. It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies, whether lying in tort, contract or otherwise, and shall bind all parties whose claims may arise out of or in any way relate to treatment or services provided or not provided by any physician, nurse practitioner, nurse, medical group or association, their partners, associates, associations, corporations, partnerships, employees, agents, clinics, and/or providers affiliated with HydraDrip (collectively herein referred to as “Company”) to a patient, including any spouse or heirs of the patient and any children, whether born or unborn at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children. Filing by Company of any action in any court by the Company to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against Company, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.
Procedures and Applicable Law. A notice or demand for arbitration must be communicated in writing by U.S. mail, postage prepaid, to all parties, describing the claim against Company, the amount of damages sought, and the names, addresses and telephone numbers of the patient, and (if applicable) his or her attorney. The parties shall thereafter select a mutually agreeable arbitrator to preside over the matter. The parties shall bear their own costs, fees and expenses, along with a pro rata share of the arbitrator’s fees and expenses.
Severability Provision. In the event any provision(s) of this Agreement is declared void and/or unenforceable, such provision(s) shall be deemed severed therefrom and the remainder of this agreement enforced in accordance with Georgia/Tennessee State and federal law.
My signature below confirms that:
I am 18 years or older and am of sound legal mind to authorize and consent to the use of IV hydration therapy.
I have disclosed all known medical conditions, medications, and any other physical or mental conditions that I have or previously had.
The procedure set forth above has been adequately explained to me by my attending medical professional.
I have received all the information and explanation I desire concerning the procedure.
This document is intended to serve as confirmation of informed consent for IV hydration therapy.