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

Schedule Disposition versions

2012-09-01

SCHEDULE II

(ss. 9 and 15)

AGREEMENT RESPECTING A DISPUTE SUBMITTED

TO CONCILIATION □

TO ARBITRATION □

Entered into between __________________________________________________________________

(name and address of patient)

hereinafter referred to as “the patient” and _________________________________________________

(name and address of acupuncturist)

hereinafter referred to as “the acupuncturist”, who state and agree as follows:

An agreement has been entered into between the patient and the acupuncturist concerning the dispute submitted:

to conciliation □

to arbitration □ applied for on _________________________

(date)

The agreement provides for the following terms and conditions:

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The patient and the acupuncturist request that the

conciliation □

arbitration □

proceedings be stayed.

______________________________________ ________________________________

(signature of patient) (signature of acupuncturist)

Signed at _____________________________ Signed at ________________________

(place) (place)

on ___________________________________ on _____________________________

(date) (date)

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