TREATMENT REFUSAL FORMS
These forms are intended to be used when a patient refuses the treatment. These forms help confirm
that the patient is informed and aware of the risks involved with not proceeding with recommended
treatment.
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No other reasonable option to dental radiographs exists at this time. ... and my refusal to take radiographs. I also understand that Dr. ______ will refuse.
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2022/2023
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TREATMENT REFUSAL FORMS
These forms are intended to be used when a patient refuses the treatment. These forms help confirm that the patient is informed and aware of the risks involved with not proceeding with recommended treatment.
Form A
(Doctor Name), DDS
(DOCTOR'S ADDRESS)
DISCUSSION AND REFUSAL OF TREATMENT
Diagnostic Radiographs (X-Rays)
Patient’s Name __________________________________ I am being provided this information and refusal form so I may fully understand the procedure recommended for me and the consequences of my refusal. I wish to be provided with enough information to make a well-informed decision regarding the proposed procedure.
It has been recommended that I have routine diagnostic radiographs based on the American Dental Associations guidelines (a full mouth series every 3-5 years and bitewings every 1-2 years). I understand that the radiographs are necessary for my dentist to diagnose and treat possible decay (cavities), infection, fractured teeth, bone loss due to gum disease, and tumors. Without periodic radiographs, my dentist cannot identify and disclose to me potential problems, which could lead to serious jaw infections, tooth loss, and bone destruction leading to potential jaw fractures.
No other reasonable option to dental radiographs exists at this time. I am informed that the dose of radiation is minimal from such dental radiographs, and that all necessary precautions will be taken to ensure exposure is minimal (lead apron, collar and digital imaging).
_____ I have had an opportunity to ask questions about dental radiographs, risks of x-ray exposure, and risks associated with not taking them.
I have received the above information about the proposed radiographs. I have discussed my treatment with Dr. ______ and have been given the opportunity to ask questions and have them fully answered. Dr. ______ has informed me of the need for dental radiographs, risks associated with not taking radiographs, and my refusal to take radiographs. I also understand that Dr. ______ will refuse to treat me if I refuse necessary diagnostic radiographs.
Signed: ________________________________________________ Date: ______________________ Patient or Guardian
Signed: ________________________________________________ Date: ______________________ Treating Dentist
Signed: ________________________________________________ Date: ______________________ Witness
Form B
Discussion and Refusal of Treatment
Patient’s Name:________________________________________ Date of Birth: ____________________ Last First Initial
I am being provided this information and refusal form so I may fully understand the treatment recommended for me and the consequences of my refusal. I wish to be provided with enough information, in a way I can understand, to make a well informed decision regarding my proposed treatment.
I understand that I may ask any questions I wish regarding the recommended treatment.
Nature of the Recommended Treatment
It has been recommended that I have the following treatment: ___________________________
This recommendation is based on visual examination(s), on any x-rays, models, photos and other diagnostic tests taken, and on my doctor’s knowledge of my medical and dental history. The treatment is necessary because of:
Decay Broken Tooth/Teeth Infection Periodontal (Gum) Disease Pain Other _____________________________________________
The intended benefit of this treatment is: _____________________________________________ The prognosis, or chance of success, of this treatment is: ________________________________ My treatment is estimated to take ___________ visits to complete. My treatment is estimated to cost $ ________________________.
Alternate Treatments The treatment recommended for me was chosen because it is believed to best suit my needs. I understand that alternative ways to treat my dental condition include ___________________________
No other reasonable treatment option exists for my condition.
______ I have had an opportunity to ask questions about these alternatives and any other treatments I have heard or thought about, including ____________________________________
Risks of the Recommended Treatment I understand that no dental treatment is completely risk free and that my dentist will take reasonable steps to limit any complications of my treatment. I understand that some after-treatment effects and complications tend to occur with regularity. These include_____________________________