Spurr Family Dentistry has thoroughly explained the nature of the condition(s) or disease(s) that may go undetected and any other potential consequences of my refusal to allow Spurr Family Dentistry to perform an examination and/or x-rays. Spurr Family Dentistry has also thoroughly explained the likelihood that these condition(s) or disease(s) risks may occur. I have discussed my reason for refusal with Spurr Family Dentistry and have been given an opportunity to ask questions and have them fully answered.
I am aware that the practice of dentistry is not an exact science and I acknowledge that no written or oral representations, warranties or guarantees have been made regarding the possible consequences of my refusal to have an examination and/or x-rays.
Taking all of the above information into consideration, being sound of mind, legal age, competent to make my own decisions, and fully understanding the nature and possible consequences of my refusal, I still wish to not have an examination and/or x-rays.
I am aware that Spurr Family Dentistry reserves the right to dismiss the patient from our practice at any time as we cannot provide proper treatment, and this could cause permanent, irreversible damage to my health.
I acknowledge that I have read this document in its entirety, that I fully understand it, and that I have noted a reason for refusal.