General Consent Form - Richland Dentistry, Plc (Page 2 of 3) in pdf

alcohol, tranquilizers, sedatives or other drugs). It is not advisable to operate any motor

vehicle or hazardous device while experiencing side effects of the medications we may

prescribe. Antibiotics are known to decrease the effectiveness of oral contraceptives, so

it is advised that other contraceptive measures be taken during the administration of

antibiotics.

X-Rays and Photos

Modern digital dental x-ray equipment exposes patients to a very low dose of radiation.

Diagnostic x-rays provide the dentists with valuable information about your teeth and

supporting bone that cannot be evaluated otherwise. Our office takes the minimum x-rays

that allow us to do a thorough exam for each patient. All patients 18 years and older will

receive a full mouth series of intra-oral x-rays and/or a panorex every 5 years. All

patients will also receive bitewing x-rays every 1-2 years depending on overall dental

risk. Without these x-rays, we cannot do a complete exam of the entire mouth and jaw.

We may also take photos of our patients as part of their permanent record. We will not

release these photos to anyone without your permission.

Specific Problem Examinations

In the event that a patient requests only a specific problem be addressed (i.e.: broken

tooth, pain in one area, etc.) this is considered a problem focused evaluation. X-rays will

be taken in this specific area only, and a complete comprehensive examination will not be

done. The dentist cannot diagnose problems in other areas of the mouth. Please

understand that this appointment will be for the diagnosis and/or treatment on an

emergency basis. Any future treatment of other areas will require additional x-rays and a

complete exam. You will not be considered a patient of record unless this examination is

completed.

Requests for records/x-rays

By law we are required to keep a patient's original x-rays and record in this office.

Original x-rays or records will NOT be released. The patient or a designated person may

request copies of their x-rays or record. We require a minimum of 5 days’ notice to copy

x-rays or record.

Specialty Referral and/or Second Opinion

General dentists perform the majority of all dental treatment today. However, we want all

patients to be aware that specialty fields exist in dentistry, particularly in the fields of oral

surgery, orthodontics, periodontics, pediatric dentistry, and endodontics. In some cases

we may have to refer certain procedures out to a specialist. We would be happy to offer

you the names of specialists in order for you to have a second opinion and/or have actual

treatment performed by a specialist.

Initial __________

General Consent Form - Richland Dentistry, Plc Page 2