X-Ray radiographs refusal form

  • Fishman Pediatric Dentistry
    552 Jacksonville Dr.
    Jacksonville Beach, FL 32250
    (904)247-4097


    This form is so that I may fully understand what is recommended for my child and the risks associated with refusing dental radiographs (x-rays).

    The American Dental Association’s and the Food and Drug Administration’s current guidelines prescribing dental radiographs (x-rays) are as follows:

    • Routine diagnostic radiographs such as a full mouth series, or panoramic x-ray should be taken every 3-5 years.
    • Bitewing x-rays should be taken every 1-2 years, unless your dentist believes the patient to be of high cavity risk. High risk patients should have their bitewings every 6-12 months.

    I understand radiographs are necessary for the dentist to fully diagnose and treat possible decay (cavities), infection, fractured teeth, and bone loss due to gum disease. If these conditions are not detected until there are visible or painful signs of disease, your child’s oral health and possibly systemic (overall) health can be seriously affected. YOUR INSURANCE MAY NOT COVER THE X-RAYS AT THE RECOMMENED INTERVALS.

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