Dental Treatment Refusal
Document a patient's informed refusal of recommended dental treatment and capture dentist and patient signatures so your practice has a clear record of the decision.
Document a patient’s informed refusal of recommended care with a clear, professional Dental Treatment Refusal form. It helps dental teams record the decision in one place, so everyone has the same understanding of what was discussed and what the patient chose.
This template includes space for the recommended treatment, the patient’s refusal, and signatures from both the dentist and the patient. That makes it easier to keep a complete record of the conversation and the final decision without extra paperwork.
If your practice needs a different review process, you can tailor the wording to match your consent language or add fields for the specific treatment being declined. You can also adjust the form to fit your office branding and the way your team documents patient communication.
Frequently Asked Questions
A dental hygienist may use this form to document that a patient was informed about recommended treatment and chose not to proceed. It creates a clear record for the dental team, including the patient’s decision and the required signatures.
It should include the recommended treatment, the patient’s refusal, and signatures from the dentist and the patient. Those details help show what was discussed and confirm that the decision was documented.
Yes. You can adjust the language to match your consent process, add fields for the treatment being declined, and update the form to reflect your office’s branding and documentation style.
