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Dental Patient Dismissal Letter

A letter that terminates a patient to dentist relationship is commonly known as a dental patient dismissal letter. This type of letter is written for many different reasons regarding dental care. Several reasons may include lack of communication, non-treatment tolerance or because a patient has failed to pay for the dental services provided.

Format and Content

While some dismissal letters require a certain format, the dental patient dismissal letter format can vary based on what the reason for dismissal of services may be. However, the basics should always be included. Basic content to be provided should be the effective date of dismissal, the reason for dismissal and any further information such as instructions or referrals to find a new dentist. Dentist contact information and any outstanding balances should also be noted.


This dental patient dismissal letter sample is written for a homemaker, Carol Ann Brunswick, who has failed to pay two dental bills that are both past due. She owes the dental provider a total of $550. Her dental care provider, Dr. Diaz, has been her dentist for about a year and a half. Her dental provider has sent numerous invoices and made phone calls to her, all of which were not responded to.