Refusal of Dental Treatment Patient Details

Refusal of Dental Treatment Contact Information

Refusal of Dental Treatment Refusal of Dental Treatment

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.