Refusal Of Recommended Treatment Form

Download a blank fillable Refusal Of Recommended Treatment Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Refusal Of Recommended Treatment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

REFUSAL OF RECOMMENDED TREATMENT
Patient name: ______________________________________ Date of birth: _______________________
You have both the right and the obligation to make decisions regarding your health care. Your dentist can
provide you with the necessary information and advice, but as a member of the health care team, you must
participate in the decision-making process. This form will acknowledge your refusal of treatment
recommended by your dentist.
Dr. _________________________________ has recommended the following treatment to me:
_____________________________________________________________________________________________
This treatment has been recommended to me for the purpose of:
_____________________________________________________________________________________________
The possible benefits of proceeding with the recommended treatment include:
_____________________________________________________________________________________________
The possible risks and complications of refusing the recommended treatment could include but are not
limited to:
_____________________________________________________________________________________________
These potential risks and complications could result in additional medical or dental treatment or
procedures, tooth loss, hospitalization, blood transfusions, or very rarely permanent disability or death.
I have chosen to refuse this treatment after considering both the recommended and alternative forms of
diagnosis and/or treatment for my condition. Each of these alternative forms of diagnosis or treatment has
its own potential benefits, risks and complications.
I certify that I have read or had read to me the contents of this form. I understand the possible advantages
from proceeding with the recommended treatment and the possible risks and consequences of refusing the
recommended treatment. I have decided to refuse the treatment recommended by my dentist. I hereby
release Dr. ________________________________ and his or her employees, partners, agents, or corporation
from any liability for any and all injuries and damages I may sustain as a result of my refusing
recommended dental treatment. I attest that I have had the opportunity to ask questions and all of my
questions have been answered to my satisfaction.
PATIENT’S SIGNATURE: _________________________________________________________
DATE: ____________________ TIME: ____________________ WITNESS: _________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Refusal Of Dental Treatment Form Refusal Of Dental Treatment Form Medical
Employee Refusal Of Medical Treatment Form Employee Refusal Of Medical Treatment Form Medical
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters
Letter Of Recommendation Request Form Letter Of Recommendation Request Form Letters

Related Categories

Parent category: Medical
Download
Go