"Dental Treatment Refusal Form"

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Dental Treatment Refusal
Patient Name:
Dentist Name:
Date:
I, the Patient named above, hereby understand and acknowledge that the following dental treatment
plan has been recommended to me by the aforementioned Dentist:
It has been explained to me that the treatment would produce the following health and hygiene benefits:
It has been explained to me that refusal of treatment carries the following risks and potential damaging
consequences to my health and/or hygiene:
Being fully aware of the benefits of the treatment and the negative repercussions of refusing, I hereby
decline treatment. In doing so, I indemnify and hold harmless the Dentist, this clinic, and all attending
staff from any liabilities due to damages that may arise from refusing this treatment.
Patient Name
Date
Guardian Name
Date
www.FreePrintableMedicalForms.com
Dental Treatment Refusal
Patient Name:
Dentist Name:
Date:
I, the Patient named above, hereby understand and acknowledge that the following dental treatment
plan has been recommended to me by the aforementioned Dentist:
It has been explained to me that the treatment would produce the following health and hygiene benefits:
It has been explained to me that refusal of treatment carries the following risks and potential damaging
consequences to my health and/or hygiene:
Being fully aware of the benefits of the treatment and the negative repercussions of refusing, I hereby
decline treatment. In doing so, I indemnify and hold harmless the Dentist, this clinic, and all attending
staff from any liabilities due to damages that may arise from refusing this treatment.
Patient Name
Date
Guardian Name
Date
www.FreePrintableMedicalForms.com