X-Ray Consent Form

"*" indicates required fields

Patient's Details

Patient's Name*

Patient's Date of Birth*

General Dentist

Name of General Dentist*

Contact Details of General Dentist*

Date of last check up with Dentist*

Date of last dental hygiene appointment*

I give permission for The Temple Practice, West Park Dental, and/or West Yorkshire Dental Referral Centre to contact my General dentist regarding my treatment*

Yes

Clinical Photographs

Clinical photographs will be stored in your clinical notes and viewed by you, staff at The Temple Practice, West Park Dental, and/or West Yorkshire Dental Referral Centre for clinical/treatment planning purposes and a clinical referral recipient

I have received an explanation of the reasons why The Temple Practice, West Park Dental, and/or West Yorkshire Dental Referral Centre wishes to take photographs of my face, mouth, and teeth.

The photographs might be used for:*

Clinical purposes relating to my treatment and kept with my confidential dental records

For demonstrating clinical techniques at scientific lectures or in papers published in scientific journals

Third ChoiceTo send to me and, if permission granted, my referring dentist on completion of treatment as a record of my Orthodontic journey

X-rays

As part of a thorough clinical examination, the clinician may take dental X-rays to help diagnose any underlying issues, identify unerupted teeth, or assist with orthodontic treatment planning. X-rays are only taken when clinically necessary (justified) and are carried out in accordance with IRMER guidelines (2006). Every X-ray taken will be reviewed, with any relevant clinical findings recorded in your dental notes. X-rays may be taken either by the clinician or by her fully trained dental nurse. We use modern equipment designed to operate with the lowest possible radiation exposure.

Risks associated with use of X-rays

X-rays are a type of electromagnetic radiation, similar to light and radio waves. However, because X-rays carry more energy than light waves, they can pass through the body, allowing us to see internal structures. As with other forms of high-energy radiation, there is a very small risk that X-rays could cause changes to cells in the body, potentially increasing the long-term risk of cancer. While the risk from a single X-ray is extremely low, it can build up gradually with repeated exposure over time. This is similar to how increased exposure to sunlight raises the risk of developing skin cancer.

Benefits of using X-rays

Your dentist’s primary concern is to ensure that any use of X-rays is clinically justified, with the benefits of accurate diagnosis and appropriate treatment far outweighing any minimal risk involved. X-rays are used to detect tooth decay that may not be visible during a routine examination, identify signs of disease, and assess the presence of missing or extra teeth, as well as potential issues with unerupted teeth. Every effort is made to keep the radiation dose as low as reasonably possible, without compromising the quality of diagnostic information. To put this into perspective, a panoramic X-ray of all your teeth and jaws (known as an OPG or OPT) carries a similar radiation dose to that of a short-haul flight to Spain.

Name of patient or parent/guardian*

Signed by patient or parent/guardian*

Date of Consent*

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