A-5.1, r. 7 - Regulation respecting the conciliation and arbitration procedure for the accounts of acupuncturists

Schedule Disposition versions

2012-09-01

SCHEDULE I

(s. 6)

APPLICATION FOR CONCILIATION

I, the undersigned, __________(name and address of patient)__________ declare under oath:

(1) ____________________________________ (name and address of acupuncturist) has claimed from me the sum of $ __________ for professional services rendered between ____________________ and ____________________ (date).

As evidenced by:

□ the account a copy of which is attached hereto

or

□ the document a copy of which is attached hereto, indicating that the amount has been withdrawn or withheld

(2) I am contesting the amount claimed for the following reasons:

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but (where applicable) I acknowledge owing the sum of $ __________ for the professional services;

(3) (a) □ I have not paid the account

or

(b) □ I have paid the account in full

or

(c) □ I have paid a portion of the account, in the amount of $ __________

(4) I am applying for conciliation by the syndic under Division II of the Regulation respecting the conciliation and arbitration procedure for the accounts of acupuncturists (chapter A-5.1, r. 7).

And I have signed Oath taken before

___________________________________

(name and function, profession, or capacity)

on _____________________________________ at ______________ on ________________

(date) (place) (date)

_______________________________________ ___________________________________

(patient’s signature) (signature)

O.C. 188-2003, Sch. I.