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Refusal of Dental Treatment

Vitta Dental

80 Park Avenue Suite 1A,
New York, NY 10016
(518) 254-6451

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Refusal of Dental Treatment( * mandatory to fill )

Doctor has advised me that the following treatment

needs to be performed on

I have had a discussion with Doctor regarding the risks, benefits, and alternatives of this treatment as well as the consequences of not proceeding, and I have had the opportunity to ask him/her any questions I have regarding my concerns about the treatment. All of my questions have been answered to my satisfaction so that I can confirm that I do NOT want the treatment.

 

I release Doctor from any liability for any ill effects that I may suffer from the failure to perform the treatment proposed to me.

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I have explained the nature, purpose, benefits, and alternatives to the proposed treatment, as well as the risks and consequences of proceeding or not proceeding with the treatment. I have answered all of the patient's questions, and believe the patient/guardian/representative fully understands my answers and explanations.

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