Patient dismissal letter

A letter template from the dentist ending the doctor and patient relationship. It states that care will end 30 days from the date of the letter, explains that the relationship has not worked after several cancelled appointments and recommendations that were not followed, and suggests the patient would be better served elsewhere. It offers to forward records at the patient’s request and to provide emergency care during those 30 days.

Use it only after the practice has documented its attempts to keep the patient in care. The dentist signs it, and the office manager keeps a copy in the chart with a note of when and how it was sent. Edit the reason to match the actual situation.