Refusal of Treatment: Dental Consent Form Template (2025)

When patients decline recommended dental treatment, proper documentation is essential for both clinical and legal reasons. A well-designed refusal of treatment consent form protects your dental practice while ensuring patients fully understand the consequences of their decision.

This article provides a comprehensive template and guidance for implementing a refusal of treatment consent form in your practice for 2025, aligned with current dental practice standards.

What To Include In A Refusal of Treatment Consent Form

A properly structured refusal of treatment form should contain several key elements to ensure it's both legally sound and patient-friendly:

Patient Identification

Begin with clear fields for patient information, including full name and date of birth. This ensures the form is correctly associated with the patient's records.

Treatment Description

Include space to specifically describe the recommended treatment being refused. This should be detailed enough that there's no ambiguity about what procedure the patient is declining.

Consequences of Refusal

Perhaps the most critical section is a clear explanation of potential consequences. This typically includes:

• Disease progression - How the condition may worsen without treatment

• Structural complications - Potential tooth or tissue loss

• Systemic health impacts - How untreated conditions might affect overall health

• Financial implications - How costs may increase if treatment is delayed

Acknowledgment Statements

Include statements confirming the patient has been fully informed about the recommended treatment, has had the opportunity to ask questions, and understands the potential consequences of refusal.

Signature Fields

Provide clear spaces for signatures, dates, and relationship indication if someone is signing on behalf of a minor or dependent adult.

How To Use This Refusal of Treatment Consent Form Template

Implementing this template in your practice is straightforward:

1. Click the "Copy" button in the section above

2. Paste the template into your preferred text editor or practice management system

3. Customize the form with your practice details and any specific information relevant to your state's regulations

4. Review the form with your dental practice attorney to ensure compliance with local laws

5. Incorporate the finalized form into your practice's documentation process

When using the form with patients, take time to verbally explain all elements, particularly the potential consequences section. This verbal explanation should be documented in the patient's chart in addition to the signed form.

Best Practices For Implementation

For maximum effectiveness and protection, follow these guidelines:

• Be specific - Clearly detail the exact treatment being refused and potential consequences

• Use plain language - Ensure the form is easily understood by patients with different literacy levels

• Document conversations - Note in the patient record that you discussed treatment options and the patient chose to refuse

• Provide a copy - Give the patient a signed copy of the form for their records

• Follow up - Schedule appropriate follow-up appointments to monitor the condition

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