Governing Law And Jurisdiction Agreement For Physician In Private Practice Template
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1Governing Law and Jurisdiction Agreement
for physician in private practice
This agreement (“Agreement”) is entered into by and between ________________________________________ and
[Name of patient]
___________________________________ (collectively, the “Parties”).
[Physician in private practice]
Governing Law
The Parties hereby agree that:
a)
all aspects of the relationship between _______________________________________________ and
[Name of patient]
______________________________ (as well as her/his agents, delegates, employees, and any
[Physician in private practice]
physicians and other independent healthcare practitioners providing medical or other healthcare and
treatment to_________________________, or in association with____________________________),
[Name of patient]
[Physician in private practice]
including without limitation any medical or other healthcare and treatment provided to
___________________________________, and
[Name of patient]
b)
the resolution of any and all disputes arising from or in connection with that relationship, including any
disputes arising under or in connection with this Agreement,
shall be governed by and construed in accordance with the laws of the province or territory of ____________________
[Province or territory]
(other than conflict of laws rules) and the laws of Canada applicable therein.
Exclusive Jurisdiction
The Parties hereby acknowledge that the medical or other healthcare and treatment received by
________________________________________from _________________________________ will be provided in the
[Name of patient]
[Physician in private practice]
province or territory of______________________________, and that the Courts of ____________________________
[Province or territory]
[Province or territory]
shall have exclusive jurisdiction to hear any complaint, demand, claim, proceeding or cause of action, whatsoever arising
from or in connection with that medical or other healthcare and treatment, or from any other aspect of the relationship
between ________________________________________ and ____________________________________________.
[Name of patient]
[Physician in private practice].
Date: ____________________________________
_________________________________________
___________________________________________
Name of patient
Signature of patient / substitute
[Please print]
decision-maker on behalf of patient
Date: ____________________________________
_________________________________________
__________________________________________
Name of physician in private practice
Signature of physician in private practice
[Please print]
03/2014
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Parent category: Legal