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

DATE

Patient Name
Address
City, State Zip

Dear ___________________,

As we discussed at your recent appointment, we have attempted to save your problem tooth with a root canal treatment. Although root canal treatment has a high success rate, it is not 100%. Unfortunately yours was one of those that did not respond to the treatment.

I would like to return the payments that you have made to date for this endodontic procedure. Please find the enclosed check for $xxx.xx. Although many dentists do not do this, I am choosing to return your payments in order to maintain the good relationship we have developed.

As a reminder, I have referred you to Dr. ________, an endodontic specialist, for consultation about whether or not specialized treatment might help the tooth. Please do not delay this, as it will further decrease the chances of successful treatment.

-or-

As a reminder, I have referred you to Dr. ________, an Oral Surgeon specialist, to discuss removal of the tooth and possible implant replacement.

Sincerely,

Dr. _______