X-Ray and Fluoride Consent

  • X-Ray Consent

    It is recommended that children have check-up (bitewing) x-rays at each 6 months recall appointment. This is required so that the doctor is able to diagnose any new decay in your child’s mouth since their last visit. The policy holder is responsible for outstanding balance if insurance does not cover additional set of x-rays.


  • Fluoride Consent

    It is the policy of the doctor to apply a fluoride application to your child’s teeth at each six months recall appointment. This is required to help prevent the chance of decay. Some insurance companies allow for fluoride at each of their recall appointments , while others have a frequency limitation, only paying for fluoride once a year.
    Note: The policy holder is responsible for any balance if insurance does not cover additional Fluoride treatment.

  • Date Format: MM slash DD slash YYYY