Consultation Agreement

This agreement for consulting services (“Agreement”) is between ----------------------- (“Dentist”) and Global Mini Implant Institute/Raymond Choi, DDS (“Dr. Choi”), for the purpose of setting forth the terms under which Dr. Choi will perform consulting services to Dentist.

1. Scope of work
Dr. Choi will perform consulting services to Dentist, including reviewing and evaluating digital radiographs, models, CT studies and limited patient records and other information provided by Dentist, and further provide Dentist with advice and opinions regarding treatment plan options and treatment related issues for Dentist’s consideration relative to a specific dental patient of Dentist.

2. Payment for services
As consideration for Dr. Choi’s performance of services, Dentist shall pay Dr. Choi as follows: $390 per case for review and evaluation of digital radiographs, models, CT studies and patient records, and preparation of treatment plan/advice/opinions. For payment, please fill the credit card info at the end of the agreement

3. Confidential Information
Prior to entering this Agreement, Dentist represents that the patient’s consent to release the necessary patient information to Dr. Choi for the purpose of providing the services described herein has been obtained. Dr. Choi shall keep all patient information confidential and shall prevent the disclosure of confidential information for any purposes other than pursuant to the terms of this Agreement

4. Disclaimer
Dentist agrees and understands that nothing in this Agreement shall constitute a promise or warranty by Dr. Choi related to the opinions or advice provided to Dentist. Dentist understands and acknowledges that he/she is seeking/obtaining Dr. Choi’s advice and/or opinion only in an advisory capacity and fully understands that Dr. Choi’s will not diagnose any specific dental condition or direct or supervise any patient treatment. The opinions expressed by Dr. Choi are solely intended to provide Dentist with additional information related to implant treatment consistent with the education and training provided at Global Mini Implant Institute. Dentist is solely responsible for making all decisions related to and/or regarding individual patient care and treatment, based upon Dentist’s own independent professional judgment and licensure, notwithstanding any opinions provided by Dr. Choi.

5. Indemnification
Dentist agrees to indemnify and hold harmless Dr. Choi and Global Mini Implant Institute and his agents and employees from any claim or action of any kind or type brought by any person or entity arising out of or related to the services provided by Dr. Choi pursuant to this Agreement.
Global Mini Implant Institute

6. Complete Agreement
This Agreement shall constitute the complete agreement between parties. No other agreement or understandings between the parties shall be valid or enforceable unless reduced to writing signed by both parties

7. Term of Agreement
This Agreement shall commence upon execution and payment by Dentist and shall relate to only one specific patient. Dentist must execute/authorize a separate Agreement for each patient for whom Dr. Choi’s review/opinions are requested. Either party may terminate this Agreement at any time, for any reason, by providing written notice to the other party.
Global Mini Implant Institute
Raymond Choi, DDS: --------------------------------------------
Dentist name:------------------------------------------------------
Signature:----------------------------------------------------------
Credit card number:----------------------------------------------
Expiration date:---------------------------------------------------
RE: (please enter patient name) --------------------------------
Date: --------------------------------------------