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Release--Alleged Malpractice Claims
RELEASE--ALLEGED MALPRACTICE CLAIMS
Release executed by [name of releasor], of [address of releasor], as releasor, to [name of physician], a physician duly licensed to practice medicine in the State of [State of license], maintaining an office at [address of physician], as releasee.
In consideration of the sum of $ [Amount paid] Dollars, receipt of which is hereby acknowledged, and in further consideration of the release by [name of physician] of all claims for the value of all professional services rendered to me in the past or as the case may be, releasor releases [name of physician] from all claims of whatever nature, known or unknown, including, without limitation, claims for personal injury and disability, pain, suffering, and mental anguish, and loss of income arising from:
the treatment of and surgery in connection with [illness or condition], which treatment and surgery commenced on [date], and was concluded on [date], and the following complications that subsequently developed:
[enumerate], which complications were allegedly caused by the negligence of [name of physician] or as the case may be.
This release shall bind me, [name of releasor], or my spouse, and my heirs, legal representatives and assigns. It shall inure to the benefit of [name of physician], and to [physician]'s heirs, legal representatives, successors and assigns. The coverage of this release is also intended to, and shall, extend to [physician's insurer], the liability insurer of [name of physician], and its successors and assigns, and to [name of hospital], located at [address of hospital], the hospital at which the above-mentioned treatment and surgery took place, and its officers, agents, employees and liability insurance carriers.
I have read this release, understand the terms used in it and their legal significance, and have executed it voluntarily.
In witness whereof, releasor executes this release at [lace of execution] on [date].
Signature Date
(Attach statement of attorney, if desired.)