OFFICE POLICIES

It is our office policy to take a full series of x-rays on every adult new patient. This helps us to treat & diagnose our patients.

Patient First Name

Patient Last Name

Patient Email Address

X-RAY RELEASE

Please select either Authorize or Decline, not both

AUTHORIZE

Authorize

I AUTHORIZE Farmington Family Dental to take a complete series of x-rays. I have not had a series of x-rays in the last 5 years. I understand that if my insurance company denies payment for these x-rays, I am responsible for the balance.

DECLINE

Decline

I DECLINE the complete series of x-rays suggested by Farmington Family Dental. I have had a complete series of x-rays in the last 5 years. You can contact Dr. ____________ _ at ____________ to obtain a copy for my records.

Office Policies

OFFICE POLICIES

X-RAY RELEASE

** Please select either Authorize or Decline, not both **

AUTHORIZE

DECLINE

Please select either Authorize or Decline, not both