I am being provided this information and refusal form so I may fully understand
recommended for me and the consequences of my refusal. I wish to be provided
information to make a well-informed decision regarding the proposed procedure.
It has been recommended that I 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 my dentist to diagnose and treat possible decay (cavities), infection,
fractured teeth, bone loss due to gum disease, and tumors. Without periodic
radiographs, my 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
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.
Hassan and have been given the opportunity to ask questions and have them
fully answered. Dr. Hassan and staff has informed me of the need for dental
radiographs, risks associated with not taking radiographs, and my refusal
to take radiographs.