Article 1: It is understood that any dispute as to dental malpractice, that is to whether any dental
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 California law,
and not by a lawsuit or report to court process except as California law provides for judicial review of
arbitration proceedings. Both parties to this contract, by entering into it, 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
Article 2: I understand and agree that this Arbitration Agreement binds me and anyone else who may
have a claim arising out of or related to all treatment or services provided by the dentist, including any
spouse or heirs of the Patient and any children, whether born or unborn at the time of occurrence of any
claim. This includes, but is not limited to, any dispute arising from tort, contract, negligence or otherwise
for monetary damage, including, without limitation, suits for loss of consortium, wrongful death,
emotional distress or punitive damages or actions brought on behalf of Patient by third parties, shall be
submitted to binding arbitration and not a lawsuit. I further understand and agree that if I sign this
Agreement on behalf of some other person for whom I have responsibility, then, in addition to myself,
such person(s) will also be bound by this Agreement, along with anyone else who may have a claim
arising out of the treatment or services rendered to that person. I also understand and agree that this
Agreement relate to the claims against the dentist and any consenting substitute dentist, as well as the
dentist’s partners, associates, associations, corporation or partnerships, and the employees, agents, and
estates of any of them. I also hereby consent to the intervention or joinder in the arbitration proceeding of
all parties relevant to the full and complete settlement of any dispute arbitrated under this Agreement.
Article 3: The arbitrator shall have the authority to award any remedy or relief that a court of the state of
California could order or grant, but no other remedy or relief. The award must be limited to the relief
available to a California state court and under California law for the cause(s) of action at issue in
arbitration. However, each party shall bear its own costs, expenses, legal fees, witness expenses, and 50%
of the arbitrator’s fees and such expenses may not be awarded against the opposing party. The provisions
of California law applicable to healthcare providers shall apply including, but not limited to, California
Code of Civil Procedure sections 667.7 and 425.13, and California Civil Code sections 3333.1 and
3333.2. I agree that the arbitrators have the same immunity from civil liability as that of a judicial officer
when acting in the capacity of arbitrator under this Agreement. This immunity shall supplement, not
supplant, any other applicable statutory or common law.
Article 4: I UNDERSTAND THAT I DO NOT HAVE TO SIGN THIS AGREEMENT TO RECEIVE
THE DENTAL SERVICES, AND THAT IF I DO SIGN THIS AGREEMENT AND CHANGE MY
MIND WITHIN 5 DAYS OF TODAY, THEN I MAY CANCEL THIS AGREEMENT BY GIVING
WRITTEN NOTICE TO THE UNDERSIGNED DENTIST WITHIN 5 DAYS OF THE DATE OF MY
SIGNATURE BELOW STATING THAT I WANT TO WITHDRAW FROM THIS ARBITRATION
Article 5: I understand that each dentist is an individual practitioner and is individually responsible for
the dental care rendered to me. I also understand that no other Dentist other than the treating dentist is
responsible for my dental care. I understand that Aava Dental, its past, present, or future owners,
shareholders, officers, board of directors, or employees are not responsible for my dental care.
Article 6: I have read and understood this Agreement. I understand that in the case of a pregnant
woman, the term “patient” as used herein means both the mother and the mother’s expected child or
By initialing below, Patient intends and acknowledges this Arbitration Agreement to cover claims arising
before the date it is signed. This Arbitration Agreement is effective as of the date of this provision of the
first care or service of any kind, whichever is earlier. Patient acknowledges to have received a signed
copy of this Agreement.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions
shall remain in full force and shall not be affected by the invalidity of any other provision.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF
DENTAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING
UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE OF THIS CONTRACT.
(Patient, Parent, Guardian or Legally Authorized Representative of Patient)
If signed by other than patient, indicate relationship:
The treating Dentist understands that he/she is the only person who is responsible for the dental care of
the patient. The Treating Dentist agrees to defend, indemnify and hold Aava Dental harmless against any
and all claims, lawsuit, or actions by Patient against Aava Dental arising out of the treatment rendered by
the treating Dentist and/or the assistants working with the treating Dentist.
Dentist’s Agreement to Arbitrate: In consideration of the foregoing execution of this Patient-Dentist
Arbitration Agreement, I likewise agree to be bound by the terms set forth in this Agreement and in the
rules specified in Article 3 above.
Dentist or Duly-Authorized Representative
I have the understanding that my dental provider maybe out5of5network and
my dental insurance may forward me the check(s) for the procedure(s) that was
performed by Aava Dental.
I am informed that upon receipt of this check, I am to sign the back of the check
(“endorse the check”) and submit (mail/hand deliver) it to the Aava Dental branch
from which I received the treatment.
If the check(s) received from the insurance company does not return to Aava
dental within 2 weeks, Aava Dental is authorized to send my balance to the
Yo tengo entendido que mi seguro dental puede no estar en conexión con Aava Dental, y mi
seguro puede enviarme el cheque a mí en vez de enviarlo a mi proveedor dental.
Estoy informado que al recibo del dicho cheque, tengo que firmar (endosar el cheque) and
entregar (mandar o llevar a mano) lo a la oficina donde habia recibido tratamiento.
Si yo recibo dicho cheque, yo endosaré el cheque al reverso y lo enviare a la oficina de Aava
Dental en donde he recibido tratamiento en dos semanas o Aava Dental esta autorizado a
mandar su balanca a una agencia de collecion.