Arbitration Agreement Form

ARBITRATION AGREEMENT CONSENT FORM

I have agreed NOT to take Dr. Diep and Medical Hair Transplant and Aesthetics to court for any potential disputes related to my hair transplant procedure. Instead, I agree to enter into arbitration with Dr. Diep and Medical Hair Transplant and Aesthetics to settle any disputes.

By signing this consent form, I or anyone representing my behalf, may not take Dr. Diep and
Medical Hair Transplant and Aesthetics to court for any legal lawsuit related to my hair transplant.

I have read and acknowledge the information given to me. I have the option of not going forward with the procedure. However, I wish to go forward with the procedure and will comply with this consent form as a legal document.

I AM VERIFYING THAT THIS CONSENT FORM WAS SIGNED BY ME PRIOR TO THE DOCTOR HAS GIVEN ME ANY MEDICATION.

Signature/Consent Form

Patient's Name(Required)
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This field is for validation purposes and should be left unchanged.