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Release Alleged Malpractice Claims
Release executed by (name), of (address), as releasor, to (physician), a physician duly licensed to practice medicine in the State of (State), maintaining an office at (address), as releasee.
In consideration of the sum of $------ (receipt of which is hereby acknowledged, and in further consideration of (the release by (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 (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 (physician) or as the case may be).
This release shall bind me, (name of releasor), (or (name), my spouse,) and my heirs, legal representatives and assigns. It shall inure to the benefit of (physician), and to (physicians) heirs, legal representatives, successors and assigns. The coverage of this release is also intended to, and shall, extend to (physicians insurer), the liability insurer of (physician), and its successors and assigns, (add, if appropriate: and to (name of hospital), located at (address), 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 (designate place of execution) on (date).
*** If Required By State Law ***
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]