Patient refusal of treatment form

A refusal of recommended treatment form that the patient signs after declining care. It opens by explaining that patients have the right and the obligation to take part in decisions about their health care. Blanks cover the patient’s name, the date, the dentist’s name, the treatment recommended, the reason for it, the possible benefits, and the risks of refusing.

Keep a supply at the front desk and in the operatories. When a patient says no to a recommendation, the dentist or treatment coordinator fills it out with the patient, explains each section, and collects a signature. The signed form goes into the chart as documentation of the conversation.