Doctor's Name:________________________________ Doctor's Phone:_______________

Clinic Phone/address/fax number:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________


1. I, ______________________________ wish to retain the services of Albert R. Bruno DC as a relief doctor for the date/s commencing from _______________ and ending on the date _______________.

Initials: ____________

2. FEE AGREEMENT:

I agree and understand that for Dr. Bruno’s services, I will pay $335.00 per day for each full day of service that Dr. Bruno provides for me and/or $235.00 for each half day of service that Dr. Bruno provides for me. *A half day constitutes no more than 4 hrs.

I also agree to pay Dr. Bruno an additional seven dollars ($7.00) for each patient he provides service to above 40 patients per day.

I also agree to pay Dr. Bruno an additional seven dollars ($7.00) for each new/final/re-exam patient evaluation he performs after the first two new/final/re-exam patient evaluations, in any given day of service he provides.

I also agree to pay Doctor Bruno for any additional time required by my clinic to provide services to my patients beyond my established working clinic hours as contracted, at the rate of $50.00 per hour or a prorated portion there of.

I also agree to pay Dr. Bruno an additional $45.00 per day of service he provides for me, if the total one way travel time exceeds 45 minutes, not to exceed 1 hour. Each additional fifteen (15) minutes of one way travel is an additional ten dollars ($10.00). *Only if applicable. *Travel fee expenses may be added to the contract fee after the first day of service by Dr. Bruno, when an estimated time of travel can be more accurately determined.

If applicable, any overnight stay required, will be at the expense of the requesting doctor. The requesting doctor may make the arrangements, subject to Dr. Bruno’s approval. In the event Dr. Bruno makes any/all arrangements, the fees for those expenses are immediately due upon request by Dr. Bruno. The requesting doctor agrees to pay an additional $35.00 per night, as an overnight fee.

Initials: ____________

3. PAYMENT OF FEES

Fees will be paid by check or cash. All fees for services will be paid at the end of the last day of contracted services, before Dr. Bruno exits the premises. A check (allowing for any undetermined additional charges) or cash will be made ready before/by the end of the last day of contracted services.

Fees for services are calculated as follows:

Standard fee for a day’s service + fee for # of patients provided service to above 40 (if applicable) + fee for exams provided after the first two performed (if applicable) + any other applicable fee.

In the event that any funds paid to Dr. Bruno by check are insufficient, the doctor agrees to pay an insufficient funds fee in the amount of $45.00, plus an additional $50.00 per day for each day the funds due to Dr. Bruno have not been paid, starting from and including the first day.

If payment for services is not received immediately following the last day of service provided, then the requesting doctor agrees to pay an additional $25.00 per day for each day, starting with the first day that agreed fee has not been received by Dr. Bruno, until payment has been received.

Initials: ____________

4. CANCELLATIONS

Cancellations of service contract for any reasons must be executed in writing to Dr. Bruno.

A cancellation fee for contracted services will be charged as follows:

a) Cancellation notice executed within seven (7) days of contracted service/s, 85% of contracted service/s.

b) Cancellation notice executed within eight (8) to fourteen (14) days of contracted service/s, 75% of contracted service/s.

c) Cancellation notice executed within fifteen (15) to thirty (30) days of contracted service/s, 70% of contracted service/s.

d) Cancellation notice executed thirty-one (31) days or greater, of contracted service/s, 50% of total contracted services.

e) Any expenses paid by Doctor Bruno which can not be recovered due to any cancellation of contracted services, will be the immediate responsibility of the retaining doctor and not refunded.

Initials: ____________

5. Malpractice Insurance

It is the responsibility of the retaining doctor to notify their malpractice insurance carrier, that a relief doctor will be providing services to their patients while they are away from their clinic.

Dr. Bruno is responsible for his own malpractice insurance and will provide the retaining doctor a copy if requested. Coverage 1 million/3 million.

Initials: ____________

6. Dispute Resolution

In the event that a dispute arises between either parties, both parties agree to submit to binding arbitration in accordance to the laws of the state of ______________________. The losing party will be responsible for all legal fees of the prevailing party.

Initials: ____________

7. Indemnification:

In the event that the retaining doctor is sued for any reasons not related to Doctor Bruno or any specific services provided by Doctor Bruno on the days of relief service provided by Doctor Bruno to any of the retaining doctors patients, the retaining doctor agrees to indemnify and hold harmless Doctor Bruno from any and all legal actions for any reasons. If Doctor Bruno is not satisfied for any reasons with the legal indemnification provided to him, he reserves the right to retain legal counsel of his choice and the fees for those services will be the responsibility of the retaining Doctor.

Initials: ____________

______________________________________
Signature of Retaining Doctor/Agent

______________________________________
Albert R. Bruno DC

Date: ____________________

*Signature constitutes acceptance & agreement of all terms & conditions of contract