Dental Exam Refusal Waiver Form
Please complete this form to formally decline a recommended dental examination and acknowledge the associated risks.
Patient Full Name
*
First Name
Last Name
Are you completing this form as the patient or as the parent/guardian?
*
Patient
Parent/Guardian
If you are a parent or guardian, please enter your full name
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
example@example.com
Reason for refusing the recommended dental examination (optional)
Waiver Statement
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Waiver
Submit Waiver
Should be Empty: