Patient Dismissal Form for Dentist

A dismissal letter that tells a patient the office can no longer provide dental care. The reason given is the need to keep a professional and respectful setting for patients and staff, after recent interactions lacked mutual respect. The letter offers emergency care for 30 days from its date, or until the patient finds another dentist, whichever comes first.

This version fits situations where a patient’s behavior toward the team is the problem, rather than missed appointments. The office manager prepares it for the dentist’s signature after the incidents are documented, sends it to the patient, and files a copy with the chart.