Refusal of Treatment Acknowledgement



  • You have the right and the obligation to make decisions regarding your healthcare . Your dentist can provide you with the necessary information and advice, but as a member of the healthcare team, you must participate in the decisionmaking process . This form will acknowledge your refusal of treatment recommended by your dentist.



  • 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 of 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 . Mason and 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.

    I understand by signing the Refusal of Treatment Form, I am terminating the Doctor/Patient relationship with Dr. Jodi Mason and Bean Tree Pediatric Dentistry. Patient will be deactivated with our practice on the day parent, guardian or authorized agent signs this form. Future care will need to be met by an alternate provider.

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