I am being provided this information and refusal form so I may fully understand the procedure recommended for the patient and the consequences of my refusal. I wish to be provided with enough information to make a well-informed decision regarding the proposed procedure.
It has been recommended that the patient have routine diagnostic radiographs based on the American Dental Associations guidelines (a full mouth series every 3-5 years and bitewings every 1-2 years). I understand that the radiographs are necessary for the dentist to diagnose and treat possible decay (cavities), infection, fractured teeth, bone loss due to gum disease, and tumors. Without periodic radiographs, the dentist cannot identify and disclose to me potential problems, which could lead to serious jaw infections, tooth loss, and bone destruction leading to potential jaw fractures.
No other reasonable option to dental radiographs exists at this time. I am informed that the dose of radiation is minimal from such dental radiographs, and that all necessary precautions will be taken to ensure exposure is minimal (lead apron, collar and digital imaging).
I have had an opportunity to ask questions about dental radiographs, risks of x-ray exposure, and risks associated with not taking them.
I have received the above information about the proposed radiographs. I have discussed my treatment with Dr. Marie and have been given the opportunity to ask questions and have them fully answered. Dr. Marie has informed me of the need for dental radiographs, risks associated with not taking radiographs, and my refusal to take radiographs. I also understand that Dr. Marie will refuse to treat me if I refuse necessary diagnostic radiographs.