MUTUAL BINDING ARBITRATION AGREEMENT

Patient’s Name: ___________________________________

This mutual binding arbitration agreement constitutes an integral part of a contract for medical

services by and between ___________________________ and __________________________

(name of physician) (name of patient)

who agree to be bound as described hereunder:

1. It is under stood that any dispute as to medical malpractice, that is, as to whether any medical services rendered under this Contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided in Nevada law, and not by lawsuit or resort to court process except as Nevada law provides for judicial review of arbitration proceedings. Both parties to this Contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

2. Such arbitration shall be in accordance with the arbitration rules of the Nevada Revised Statutes. This Mutual Binding Arbitration Agreement shall apply to any legal claim or civil action in connection with any and all medical care or medical services rendered, whether inpatient or outpatient, against Dr. _______________ or any of Dr. ______________’s employees or contracted staff.

3. The execution of this Mutual Binding Arbitration Agreement shall not be a precondition of the furnishing of medical services by Dr. _____________________. This Mutual Binding Arbitration Agreement may be rescinded by written notice from the Patient or Patient’s legal representative within 30 days of signature.

4. The Mutual Binding Arbitration Agreement shall bind the parties hereto, including newborns, and the heirs, representatives, executors, administrators, successors, and assigns of such parties and newborns.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Date: ___________________________ Time: ____________________ A.M./P.M.

Signature: _______________________________________________________

(patient/parent/legal guardian/legal representative)

If signed by other than patient, indicate relationship: ________________________________