If and only if you would like to decline a service please sign below for declination:
Declination of Topical Fluoride/ Varnish
I have been informed of the need for necessary topical fluoride/ varnish and I voluntarily decline this procedure. I am aware that potential dental problems may occur because of this refusal. I assume full responsibility for any dental or medical conditions relating to the patient’s health that may have been related to the fluoride application. Therefore, I agree to indemnify and hold harmless Dr. Ivette Diaz for any liabilities due to the lack of recommended fluoride treatment. I am also aware that my refusal goes against ABC123 Pediatric Dentistry’s professional advice.