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

Full text
SCHEDULE I
(s. 6)
APPLICATION FOR CONCILIATION
I, the undersigned, __________(name and address of patient)__________ declare under oath:
(1) ____________________________________ (name and address of acupuncturist) has claimed from me the sum of $ __________ for professional services rendered between ____________________ and ____________________ (date).
As evidenced by:
□ the account a copy of which is attached hereto
or
□ the document a copy of which is attached hereto, indicating that the amount has been withdrawn or withheld
(2) I am contesting the amount claimed for the following reasons:




but (where applicable) I acknowledge owing the sum of $ __________ for the professional services;
(3) (a) □ I have not paid the account
or
(b) □ I have paid the account in full
or
(c) □ I have paid a portion of the account, in the amount of $ __________
(4) I am applying for conciliation by the syndic under Division II of the Regulation respecting the conciliation and arbitration procedure for the accounts of acupuncturists (chapter A-5.1, r. 7).
And I have signed Oath taken before
___________________________________
(name and function, profession, or capacity)
on _____________________________________ at ______________ on ________________
(date) (place) (date)
_______________________________________ ___________________________________
(patient’s signature) (signature)
O.C. 188-2003, Sch. I.