Dear Doctors and Team Members,

Knowing that anyone at anytime can say they did not hear or understand has created many law suites.  This will help each of you prevent that from happening.  

Refusal of Recommended Treatment



Patient name_______________________________________  Date_______________________


You have the right and the obligation to make decisions regarding your healthcare. Your dentist can provide you with the necessary information and advice, but as a member of the healthcare team, you must participate in the decision-making process. This form will acknowledge your refusal of treatment recommended by your dentist.


Dr. ________________________________________has recommended the following treatment to me: __________________________________________________________________________________



This treatment has been recommended to me for the purpose of: _______________________________


The possible benefits of proceeding with the recommended treatment include: ___________________


The possible risks and complications of refusing the recommended treatment could include but are not limited to: __________________________________________________________________________



These potential risks and complications could result in additional medical or dental treatment or procedures, tooth loss, hospitalization, blood transfusions, or, very rarely, permanent disability or death.


I have chosen to refuse this treatment after considering both the recommended and alternative forms of diagnosis and/or treatment for my condition. Each of these alternative forms of diagnosis or treatment has its own potential benefits, risks and complications.


I certify that I have read or had read to me the contents of this form. I understand the possible advantages of proceeding with the recommended treatment and the possible risks and consequences of refusing the recommended treatment. I have decided to refuse the treatment recommended by my dentist. I hereby release Dr. __________________________________ and his/her employees, partners, agents or corporation from any liability for any and all injuries and damages I may sustain as a result of my refusing recommended dental treatment. I attest that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

Patient signature___________________________________________Date ____________________

Printed name if signed on behalf of patient&relashionship) _________________________Date_____                  

Witness signature__________________________________________ Date_____________________

Dentist signature___________________________________________Date ____________________

Christine Taxin
36 Abington Avenue
Ardsley New York 10502
United States of America