X-Ray Refusal Form

Refusal of dental radiographs (X-rays)

Patient Information

Patient's First Name *

Patient's Last Name *

Parent/Guardian Name *

Patient's DOB *

Email *

X-Ray Refusal

I, the undersigned parent/legal guardian, hereby refuse to allow dental radiographs (X-rays) to be taken of my child at this time.

I understand that dental radiographs are an important diagnostic tool that helps the dentist:

Detect cavities between teeth and under existing restorations
Identify infections, abscesses, and cysts
Monitor the development of permanent teeth
Evaluate the health of bone supporting the teeth
Detect tumors or other abnormalities
Plan orthodontic treatment

I understand that by refusing dental X-rays, the dentist's ability to diagnose and treat my child's dental conditions may be limited. Conditions that could have been detected early may go undiagnosed, potentially leading to more extensive and costly treatment in the future.

I accept full responsibility for any consequences resulting from my decision to refuse dental radiographs for my child.

Reason for Refusal

I acknowledge that refusing dental X-rays may limit the dentist's ability to fully diagnose and treat my child's dental conditions, and I accept responsibility for this decision.

Signature

Parent/Guardian Signature (Type Full Name) *