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Download a copy, print it, send it by email, or mail it via USPS—whatever works best for your next step.

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If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.

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Go online and find the ADA. They offer a form on their website specifically for filing a complaint. There will be a link in the website for this. After the complaint is filed and recieved the ADA will give you an option to have a mediation with your dentist to try and come to a resolvement regarding your complaint.
A dentist has the right to refuse to treat you. He is not obligated to perform a service that you want just because you want it. Nor does he have to perform any treatment that he feels would be better done by a specialist. However, a dentist cannot abandon you during treatment.
In its most basic terms, informed consent is the conversation during which the dentist gives the patient information about: Any dental health problems that the dentist observed. The nature of any proposed treatment. The potential benefits and risks associated with that treatment. Any alternatives to the proposed ...
Be Honest and Direct: Explain your reasons for wanting to refuse the treatment. You might say something like: - ``I've been thinking about the crown treatment, and I've decided I would like to withdraw my consent. I appreciate your recommendation, but I have some reservations.''
If the patient's refusal puts them at significant risk of injury, an informed refusal discussion is necessary. The informed refusal helps in several ways: Improves documentation by capturing the physician's efforts at providing the best possible care. Expresses the severity and consequences of the refusal.
You can decline anything you wish. The dentist can't force you to do anything against your wishes. Also, with out proper x-rays, the dental office has the right to decline care.
Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.
Informed refusal may indicate that you and the patient have different values and expectations. Consider whether it would be best if that patient is dismissed from the practice and referred to another dentist. Example: the patient who refuses a radiograph you believe essential to proper diagnosis and treatment.
Do I need to see the dentist if I have healthy teeth? Yes, even if you take good care of your teeth, going to the dentist should still be part of your routine because even though your teeth look healthy, you likely still have some plaque on your teeth or tartar on your gums that can lead to tooth decay and gum disease.
For information on filing a complaint call 1-800-442-8106 or email conduct@nysed . Please note, complaints must be submitted in writing and cannot be filed by phone.