Dental Imaging Refusal Form
Please complete this form to document your decision to decline recommended dental imaging. All information will be recorded for our records.
Patient Full Name
*
First Name
Last Name
Date of Refusal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Email Address
*
example@example.com
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Dental Imaging Declined
*
Please Select
Bitewing X-ray
Panoramic X-ray
Periapical X-ray
Cone Beam CT
Other
Reason for Declining Imaging (optional)
Please confirm that you understand declining recommended dental imaging may limit diagnostic capabilities.
*
I understand and wish to proceed with refusal.
Submit Refusal
Should be Empty: