Release executed by __________ (name), of __________ (address), as releasor, to __________ (physician), a physician duly licensed to practice medicine in the State of _____, maintaining an office at ___________ (address), as releasee.
In consideration of the sum of ___________ Dollars ($_receipt of which is hereby acknowledged, and in further consideration of ________ (the release by ______________ (physician) of all claims for the value of all professional services rendered to me in the past or as the case may be), releasor releases __________ (physician) from all claims of whatever nature, known or unknown, including, without limitation, claims for personal injury and disability, pain, suffering, and mental anguish, and loss of income arising from:
__________ (the treatment of and surgery in connection with ___ (illness or condition), which treatment and surgery commenced on ___ (date), and was concluded on ___________ (date), and the following complications that subsequently developed:
___________(enumerate), which complications were allegedly caused by the negligence of ______________ (physician) or as the case may be).
This release shall bind me, _____________ (name of releasor), (or _________ (name), my spouse,) and my heirs, legal representatives and assigns. It shall inure to the benefit of _________ (physician), and to __________ (physicians) heirs, legal representatives, successors and assigns. The coverage of this release is also intended to, and shall, extend to __________ (physicians insurer), the liability insurer of ______ (physician), and its successors and assigns, (add, if appropriate: and to _________ (name of hospital), located at __________ (address), the hospital at which the above-mentioned treatment and surgery took place, and its officers, agents, employees and liability insurance carriers).
I have read this release, understand the terms used in it and their legal significance, and have executed it voluntarily.
In witness whereof, releasor executes this release at _______ designate lace of execution) on ______ (date).
(Attach statement of attorney, if desired.)