After reading each below statement, please type your initials in each box.

Women Only

All claims and disputes arising under or relating to any and all treatments prescribed by AMOWC are to be settled by binding arbitration in Hillsborough County, Florida. The arbitration shall be conducted on a confidential basis pursuant to the Commercial Arbitration Rules of the American Arbitration Association. Any decision or award as a result of any such arbitration proceeding shall be in writing and shall provide an explanation for all conclusions of law and fact and shall include the assessment of costs, expenses, and reasonable attorneys' fees. Any such arbitration shall be conducted by an arbitrator experienced in medical law and shall include a written record of the arbitration hearing. The parties reserve the right to object to any individual who shall be employed by or affiliated with a competing organization or entity. An award of arbitration may be confirmed in a court of competent jurisdiction. If you have no questions regarding the above, please type your signature below or insert electronic signature if available. Type your signature or insert electronic signature if available. Any questions you may have can be discussed during your session with the physician and the consent form signed afterwards. I have read and understand all of the above.