Form

Refusal of Periodic Exam

I am being provided this information and refusal form so I may fully understand the procedure recommended for me and the consequences of my refusal.

I wish to be provided with enough information to make a well-informed decision regarding the proposed procedure.

It has been recommended that I have routine diagnostic exam based on the American Dental Association’s guidelines.

Potential benefits:

I understand that dental exams are necessary as there is no reasonable alternative to completely diagnosis and treat many conditions including, but not limited to, the following:

Tooth decay (cavities)
Dental infection
Fractured teeth
Bone loss
Bone destruction
Tumors
Jaw infections
Tooth loss

I have received the above information about dental examinations. I have discussed my treatment with my dentist and have been given the opportunity to ask questions and have them fully answered. The dentist has informed me of the need for dental examinations, risks associated with not having periodic examinations, and my refusal to have a dental examination. I also understand that my dentist may refuse to treat me if I refuse necessary periodic examinations.

First Name

Last Name

Date Of Birth

Signature

Date