Radiograph Refusal Form

Declining Dental X-Rays

Dental X-rays (radiographs) are an important tool that helps our team diagnose conditions that may not be visible during a standard exam. However, if you choose to decline X-rays, please complete this secure Radiograph Refusal form so we can document your decision.

This form confirms that you understand the importance of radiographs and are choosing to refuse them at this time.

Questions About Dental X-Rays?

If you have concerns about radiation exposure, frequency of X-rays, or how radiographs are used in your care, please speak with our clinical team. We’re happy to answer your questions and help you make an informed decision.

Need Assistance?

If you prefer to complete this form in our office or need help with the process, please call us at (512) 451-8256.