Chairside Work Authorization Form

  1. This document serves as my written work authorization for all chairside procedures the clinical support technician has been contracted
    to perform.
  2. In consideration for performing dental laboratory services and other valuable consideration, and in consideration of the fact that the
    dental laboratory services are being provided on our premises for our convenience and the convenience of our patient(s), I hereby
    RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE ROE Dental Laboratory (hereinafter referred to as RELEASES) from any and
    all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be
    sustained by our practices dental patients relative to onsite interaction with a representative of the dental laboratory during Chairside
    services, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASES, or otherwise, while participating in such activity, or while in, on or
    upon the premises where the activity is being conducted.
  3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASES from any loss, liability, damage or costs, including court
    costs and attorney’s fees, that RELEASES may incur due to participation in said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASES
    or otherwise.
  4. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the
    State where clinical support is being performed.
  5. I hereby agree to the fee associated with the procedures following the fee schedule attached.
    IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless
    Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart
    from the foregoing written agreement, have been made; and I execute this Release for full, adequate and complete consideration fully
    intending to be bound by same.

Chairside Support Authorization

  • Date Format: MM slash DD slash YYYY
  • A cancellation fee will incur when a clinical support visit is cancelled after being confirmed. The cancellation fee is $500 pus any travel expenses that cannot be refunded.
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