X-Ray and Fluoride Consent - Fishman Pediatric Dentistry

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.

Select One*

I want to be aware of any possible changes in the health of my child’s teeth and would like x-rays taken every six months.
I only want x-rays taken once a year. I understand that decay may be present that cannot be detected, which may result in more extensive fillings or crowns being required after their appointment.
I do not want x-rays taken at all. I understand that the dentist will not be able to fully examine my child. I release Fishman Pediatrics from any responsibility for any condition which may be present in my child's mouth that remains undiagnosed as a result of my request that no dental radiographs be taken.

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.

Select One*

I want fluoride applied to my child’s teeth at every six months.
I only want fluoride once a year. I am aware that the lack of fluoride may help to promote tooth decay.
I do not want fluoride AT ALL. I am aware that the lack of fluoride may help to promote tooth decay.

Child's Name*
First Last

Child's Name
First Last

Parent's Signature*

Date*
MM slash DD slash YYYY

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