Patient Request for Mediation

Confidential

Upon receipt of this completed form a mediator will be assigned and will contact you to discuss your request and help resolve the issue. While a refund of a fee you have paid is one of the options that may be recommended by the mediator, a request for a refund should NOT be made in writing or with this form.

By submitting this form you are saying that you agree with the following statement (Submission of this form will serve as your electronic signature):

In order for a complete review to be performed, I authorize the release to this committee, for any dental records or information by anyone who has examined me previously. I further give my permission for the committee to perform a clinical examination if necessary.