ORDRE DES DENTISTES DU QUÉBEC
Application for conciliation
I, the undersigned ___________(name and address)___________ in person or (where applicable) representing _________________________________ for the purposes of this application, as attested by the authorization annexed hereto, declare that:
(1) Doctor ___________(name of dentist)___________ claims from me the sum of $___________ for professional services rendered between _________________________________ and _________________________________ as attested by the account a copy of which is annexed hereto;
(2) I refuse to pay this account for the following reason(s):
but (where applicable) I acknowledge that I owe the sum of $___________ for the professional services referred to in such account;
(3) I apply for conciliation by the syndic pursuant to Division II of the Regulation respecting the procedure for conciliation and arbitration of accounts of dentists (chapter D-3, r. 12), of which I declare having received a copy and taken cognizance.
signature of patient or his duly authorized representative