Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)

Date

Patient Name
Patient Address
City, State  Zip

Dear ____,

I have always felt that it is imperative to have a good two-way Doctor-Patient relationship with any patient I treat.  Unfortunately I don’t believe we have been able to reestablish this connection since you returned to the practice on Jan 17, 2013 after a seven year absence.

To get the type of dental care you are looking for, I feel you would be better served at another dental office. 

We will forward x-rays and/or records to another dentist at your request; an authorization to release your records is enclosed.

The office will be available for 30 days for emergency treatment only, so that you have adequate time to find another dentist.  If you need assistance in finding another dentist, you may contact the local Dental Society at 555-555-5555, or consult the telephone directory.

Remember that you have at least two teeth that need fillings, upper left bicuspid and lower left molar.  The longer it is delayed, the deeper the decay will go, and could result in loss of these teeth.  You also should have a complete comprehensive exam also, since you have had only emergency treatment at our office.

Sincerely,

Dr. ______