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.

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: __________________________________________________________________________________

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

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

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

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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) __________________________

Witness signature__________________________________________ Date_____________________

Dentist signature___________________________________________Date ____________________