Downtown Whitby Dentistry

Informed Refusal of Neccessary X-Rays Consent Form

130 Byron Street North, Whitby, ON, L1N 4M9      905-430-7045

Patient's Name:
E-mail Address
Dr. Nematollahi as advised me to have necessary X-rays for the accurate diagnosis and treatment of possible dental conditions in my oral cavity.

The Doctor and/or staff have explained the importance of using the disgnostic tool and have discussed with me the potential risks of not having the prescribed xrays on my oral health.

I understand that the radiographs are necessary for my Dentist to diagnose and treat possible decay (cavites) infection, fractrued teeth, bone loss due to gum disease and tumors.

Without perioedic radiographs (xrays), my Dentist cannot identify and disclose to me potential problems, which could lead to serious jaw infections, tooth loss and bone destruction.

Patient Consent

Signature