Treatment Decline Supplemental Informed Consent
I, , have declined my orthodontist's recommendation to have progress orthodontic records made or recommended treatment performed.
I realize that my refusal might compromise my (my child’s) orthodontic result in one or more of the following ways:
These problems could lead to tooth loss or severe problems with the gums or bones.
Additional Comments:
I agree to hold my orthodontist blameless for any consequences that might arise from my refusal to have orthodontic records made or treatment recommendations declined.
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Document Name: Treatment Decline Supplemental Informed Consent
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