Dental Premedication Refusal Form
Please complete this form to document your decision to decline premedication before your dental procedure. All information will be used solely for procedural documentation.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Scheduled Procedure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Dental Procedure
*
Please Select
Cleaning
Filling
Extraction
Root Canal
Crown/Bridge
Other
Reason for Declining Premedication
Have you discussed the risks and benefits of premedication with your dental provider?
*
Yes
No
Date of Refusal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
By checking this box, I acknowledge that I have been informed of the potential risks of declining premedication and that I choose to proceed without it.
*
I acknowledge and decline premedication
Submit Refusal
Should be Empty: