Refusal of Treatment

A form that documents a patient’s decision to decline recommended treatment. It explains the patient’s right to make decisions about their care, then gives space for the doctor’s name, the recommended treatment, its purpose, the possible benefits of going ahead, and the possible risks of refusing. The patient then states the choice to refuse and signs.

Use it whenever a patient turns down treatment the dentist has recommended. The doctor or treatment coordinator should fill in the blanks in plain language, review them with the patient, and scan the signed form into the chart so the discussion is on record. It also helps when the patient returns later and the team needs to see what was offered.