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

Schedule Disposition versions

2016-01-01

SCHEDULE 2

(s. 3.01.01)

ORDRE DES DENTISTES DU QUÉBEC

Submission to arbitration

Entered into by:

---

name and address

in person or (where applicable) representing __________ for the purposes of this submission, as attested by the authorization annexed hereto, hereinafter referred to as “the party of the first part”, and

---

name and address

member of the Ordre des dentistes du Québec, hereinafter referred to as “the party of the second part”, who make the following declarations and agreements:

(1) The party of the second part claims from the party of the first part the sum of $__________ for professional services rendered between ______________________________ and ______________________________ as attested by the account a copy of which is annexed hereto;

(2) The party of the first part refuses to pay this account for the following reason(s):

---

---

---

but (where applicable) the party of the first part acknowledges that he owes the sum of $__________ for the professional services referred to in such account;

(3) The party of the first part renounces the benefit of any time elapsed with respect to prescription;

(4) The dispute between the parties bears on the entire account or (where applicable) on that part of the account which exceeds that which the party of the first part acknowledges to owe to the party of the second part, namely, the sum of $__________;

(5) The dispute between the parties will be settled by arbitration held in accordance with Division III of the Regulation respecting the procedure for conciliation and arbitration of accounts of dentists (chapter D-3, r. 12), of which the parties declare having received a copy and taken cognizance;

(6) The party of the second part undertakes for the duration of the arbitration, not to claim before the civil courts that part of the account which is the object of the dispute;

(7) The arbitration award is binding upon the parties and the rules set forth in Title II of Book VII of the Code of Civil Procedure (chapter C-25.01) apply to its enforcement;

(8) This submission may be annulled only with the written consent of the parties.

________________________________________ ________________________________________

signature of patient or his signature of dentist

duly authorized representative

Signed at ________________________________ Signed at ________________________________

the_________________________ 20__________ the__________________________ 20__________

R.R.Q., 1981, c. D-3, r. 10, Sch. 2; I.N. 2016-01-01 (NCCP).

2012-09-01

SCHEDULE 2

(s. 3.01.01)

ORDRE DES DENTISTES DU QUÉBEC

Submission to arbitration

Entered into by:

---

name and address

in person or (where applicable) representing __________ for the purposes of this submission, as attested by the authorization annexed hereto, hereinafter referred to as “the party of the first part”, and

---

name and address

member of the Ordre des dentistes du Québec, hereinafter referred to as “the party of the second part”, who make the following declarations and agreements:

(1) The party of the second part claims from the party of the first part the sum of $__________ for professional services rendered between ______________________________ and ______________________________ as attested by the account a copy of which is annexed hereto;

(2) The party of the first part refuses to pay this account for the following reason(s):

---

---

---

but (where applicable) the party of the first part acknowledges that he owes the sum of $__________ for the professional services referred to in such account;

(3) The party of the first part renounces the benefit of any time elapsed with respect to prescription;

(4) The dispute between the parties bears on the entire account or (where applicable) on that part of the account which exceeds that which the party of the first part acknowledges to owe to the party of the second part, namely, the sum of $__________;

(5) The dispute between the parties will be settled by arbitration held in accordance with Division III of the Regulation respecting the procedure for conciliation and arbitration of accounts of dentists (chapter D-3, r. 12), of which the parties declare having received a copy and taken cognizance;

(6) The party of the second part undertakes for the duration of the arbitration, not to claim before the civil courts that part of the account which is the object of the dispute;

(7) The arbitration award is binding upon the parties and the rules set forth in Book VII of the Code of Civil Procedure (chapter C-25) apply to its enforcement;

(8) This submission may be annulled only with the written consent of the parties.

________________________________________ ________________________________________

signature of patient or his signature of dentist

duly authorized representative

Signed at ________________________________ Signed at ________________________________

the_________________________ 20__________ the__________________________ 20__________

R.R.Q., 1981, c. D-3, r. 10, Sch. 2.