D-3, r. 12 - Regulation respecting the procedure for conciliation and arbitration of accounts of dentists

Schedule Disposition versions

2012-09-01

SCHEDULE 1

(s. 2.02)

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):

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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.

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signature of patient or his duly authorized representative

R.R.Q., 1981, c. D-3, r. 10, Sch. 1.