Form

Refusal of Diagnostic Radiographs

I am being provided this information and refusal form so I may fully understand the procedure recommended for me and the consequences of my refusal.

I wish to be provided with enough information to make a well-informed decision regarding the proposed procedure.

It has been recommended that I have routine diagnostic radiographs based on the American Dental Association’s guidelines (a full mouth series every 3-5 years and bitewings every 1-2 year).

Potential Benefits:

I understand that dental x-rays are REQUIRED, as there is no reasonable alternative to completely diagnosis and treat many conditions, including the following:

Tooth decay (cavities)
Infection - Fractured teeth
Bone loss due to gum disease
Jaw infections
Tooth loss
Bone destruction

Risks of X-ray Exposure:

I am informed that the dose of radiation is minimal from such dental radiographs, and that all necessary precautions will be taken to ensure exposure is minimal (lead apron, collar and/or digital imaging).

I have had an opportunity to ask questions about dental radiographs, risks of x-ray exposure, and risks associated with not taking them.

I have received the above information about radiographs. I have discussed my treatment options with my dentist. I have been given the opportunity to ask questions and have them fully answered. The dentist has informed me of the need for dental radiographs, risks associated with not taking radiographs, and my refusal to take radiographs. I also understand that my dentist may refuse to treat me if I refuse necessary diagnostic radiographs.

First Name

Last Name

Date Of Birth

Patient / Legally Authorized Representative Signature

Date

Name if signed on behalf of patient

Relationship if signed on behalf of patient