Patient information · CID-ADM-09 · v1.0

Recommended Treatment Refusal

Documents informed refusal of a recommended treatment, not merely an examination or scan.

About 6 minutesRead, sign and download from your own device

Completion

0 of 16 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Before you sign

Review this document before your appointment when possible. Your treating dentist must still explain the patient-specific treatment, benefits, material risks, alternatives—including no treatment—and answer your questions. Do not sign after receiving sedating medication.

1. Who this form is for

Fields marked * are required for a signed PDF.

Patient full legal name *Date of birth *Email *Phone *

Treating dentist

Dr. Jain & Dr. Gupta

Treating office *Signer full legal name *Enter the patient’s name when the patient is signing. An authorized representative must enter their own name.Relationship or authorityRequired when someone other than the patient signs.

2. What you are agreeing to

Purpose of this form

This form records a decision to decline recommended TREATMENT — a surgery, an extraction, a graft, periodontal therapy, a restoration, or a referral — after discussion with the treating dentist. The practice's separate Recommended Examination or Imaging Refusal covers declining a diagnostic service.

Declining is your right. This form exists so that the conversation, the reasons, and the consequences are recorded accurately for both of us. It does not end your care, and you may change your mind at any time.

Possible consequences of declining

The condition may worsen, and pain, infection, swelling, or abscess may develop.
Bone loss may continue, reducing what is available for implants and making later treatment longer, harder, and more expensive.
Teeth or implants that could have been saved may become unsavable, and may be lost.
Infection can spread into the face, neck, or bloodstream and become a medical emergency.
A tooth or site left untreated can affect neighboring teeth, the bite, and existing restorations.
The dentist may be unable to guarantee, warrant, or continue related treatment that depends on the declined care being done.

What has not changed

You remain a patient of the practice and may ask for this treatment at any time.
You will still be seen for emergencies and for care you do accept.
Nothing here waives the practice's obligations to you, and no part of it is a release from responsibility for care that is actually given.

3. Your case, in your words

Treatment, tooth number(s), or area declinedDentist's reason for recommending itAlternatives offered and discussedYour reason for decliningOptional. Cost, timing, and wanting another opinion are all legitimate reasons.Questions asked and answers received

4. Confirm, then sign

I understand what treatment was recommended, why it was recommended, what alternatives exist, and what may happen if I do not have it.I had an opportunity to ask questions, my questions were answered in language I understand, and I am choosing to decline at this time.I understand that I may change my mind and ask for this treatment at any time, and that declining does not end my care at this practice.I agree to sign this form and receive it electronically. I understand this agreement applies only to this form, and that I can complete this and any other form on paper instead — completing forms on paper does not affect my treatment, my fees, or my care in any way.I understand that I may withdraw my agreement to sign electronically at any time before I sign by simply not signing and asking the office for a paper copy, and that after signing I may ask the office for a paper copy at no charge.I understand that I need a current web browser and a device able to open and save a PDF file, that I should download and keep the PDF this form produces, and that I can ask the office to print or re-send my signed form at any time.I intend my drawn or typed signature to be my electronic signature on this form, and I am signing it myself.

Patient or authorized representative signature *

Sign inside the box using a mouse, stylus, or finger.

Where this form goes

Nothing you type here is uploaded — the signed PDF is built in your browser. Download the signed PDF saves it to your device and sends nothing. Bring it to your appointment or hand it to the front desk, and staff will place it in your dental record.

Completion

0 of 16 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Need help? Call the office before signing. A patient form should document a conversation, not replace one.

Who is responsible for this document

Responsible clinicians

Dr. Sambhav (Sam) Jain, DMD, MS
Lead Implant Dentist & Founder · CA Dental License #50472
Dr. Arpana Gupta, DDS, MDS
Implant Dentist · CA Dental License #50467

Arpana Gupta, DDS and Sambhav Jain, DDS, Inc., practicing as Center for Implant Dentistry.

Where to reach us

Fremont
3381 Walnut Ave, Fremont, CA 94538
Phone (510) 574-0496 · Fax (510) 574-0499
San Francisco
4318 Geary Blvd, Suite 201, San Francisco, CA 94118
Phone (415) 696-2922 · Fax (510) 574-0499

Questions about a form? info@bayareaimplantdentistry.com — that address is for questions about a form, not for sending one. A completed form holds health details that should never travel through ordinary email: download the signed PDF and bring it to your appointment, or hand it to the front desk.

What happens to what you type

While you type, nothing is sent and no draft, analytics, or advertising script records your answers. Download builds the PDF in your browser, saves it to your device, and sends nothing — this website never transmits your completed form. Hand it to our staff at your visit so they can place it in your record. Once accepted there, it becomes part of your dental record and is protected under California’s Confidentiality of Medical Information Act (Civil Code § 56) and, where it applies, HIPAA. You can read how we handle records in our health information privacy notice.

Controlled document CID-ADM-09 · v1.0 · Effective 06 Sep 2026 · Next clinical review 06 Sep 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS