• Your child is scheduled to have the one or more of the following services rendered: Oral Examination, Dental Prophylaxis/Cleaning, Intraoral X-rays, and/or Fluoride Application.
  • Date Format: MM slash DD slash YYYY
  • 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.

  • Declination of Diagnostic Dental X-Rays

    I have been informed of the need for the necessary diagnostic dental x-rays 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 diagnosed if the recommended diagnostic x-rays had been performed. Therefore, I agree to indemnify and hold harmless Dr. Ivette Diaz for any liabilities such as failure to diagnose or misdiagnosis due to the lack of recommended x-rays. I am also aware that my refusal goes against ABC123 Pediatric Dentistry’s professional advice.

  • This field is for validation purposes and should be left unchanged.