X-Ray radiographs refusal form - Fishman Pediatric Dentistry

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.

Please indicate one of the following:*

I have brought x-rays that have been taken within 12 months.
New x-rays can be taken today. I am aware that if my insurance does not cover these, I am held responsible.
I do not want x-rays taken today. I understand that the dentist will not be able to fully examine my child. I release Fishman Pediatric Dentistry 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.

Child's Name*

First Last

Child's Name

First Last

Child's Name

First Last

Child's Name

First Last

Parent/Legal Guardian*

First Last

Date*

Parent's Signature*