Free X-Ray Refusal Form Template

When patients hesitate to undergo X-rays, clear communication is essential. This X-Ray Refusal Form template helps you document patient refusals while ensuring they understand the risks involved. Benefit from a structured approach to obtaining consent, improving patient communication, and maintaining compliance with regulations. Plus, the WCAG-aligned design ensures accessibility for all patients. Explore how this form can enhance your practice with a simple click.

When to use this form

Use this form when a patient declines diagnostic X-rays during a dental exam, emergency visit, or pre-treatment check. It documents informed refusal, outlines risks, and records any alternatives offered, so you can continue care responsibly. Dentists, hygienists, and clinic admins benefit from clear records that reduce disputes and support compliance. Common scenarios include pregnancy, radiation concerns, recent images elsewhere, cost limits, or personal beliefs. Have patients complete it at check-in or chairside before you start procedures or treatment planning. If you also manage vaccine opt-outs, pair this workflow with the Influenza declination form and the COVID-19 Vaccine declination form to keep your policies consistent.

Must Ask X-Ray Refusal Questions

What is your main reason for declining imaging today?
Knowing the reason lets you tailor education or find suitable alternatives. Clear documentation of the patient's rationale improves clinical decisions and protects your records.
Do you understand the risks of refusing X-rays, such as missed decay, infection, fractures, or bone loss?
This confirms informed refusal and sets expectations about diagnostic limits. It also reduces disputes about outcomes or delays in treatment.
Is your decision for this visit only, or until a specific date or event?
Defining the scope tells your team when to revisit the topic and when reminders are due. It prevents repeated questioning and ensures follow-up at the right time.
Would you consider any alternatives, such as reviewing prior images, taking limited views, using lead shielding, or postponing until after pregnancy?
Offering options shows you attempted reasonable accommodations. If a patient accepts an alternative, you can proceed safely while honoring their concerns.
Are you having urgent symptoms like severe pain, swelling, trauma, or fever that may require imaging for safe treatment?
This helps you triage and decide whether refusal can be honored or if emergency care is needed. If refusal stands, mirror the clarity you use in your Vaccine consent form to document risks and next steps.

More Forms

Question		Response
Patient full name		John Smith
Date of birth		2025-10-15T00:00:00.000Z
Phone number		555 555 5555
Email address		[email protected]
Patient ID or chart number (if available)		This is a test
Date of refusal		2025-10-15T00:00:00.000Z
Treating clinician/provider name		This is a test
Facility or practice name		This is a test
Area or body part for the recommended X-ray		Chest
Reason the X-ray was recommended (select all that apply)		Diagnosis of symptoms
I have been informed of the recommended X-ray and its purpose.		Strongly disagree
I understand potential risks of refusing the X-ray (for example, delayed or missed diagnosis, progression of condition).		Neither agree nor disagree
Alternatives, benefits, and risks were discussed where appropriate.		Agree
I had the opportunity to ask questions and they were answered to my satisfaction.		Strongly disagree
My decision to refuse is voluntary and I understand I may change my decision at any time.		Agree
Is your refusal temporary or ongoing?		Undecided
Primary reason(s) for refusing the X-ray today		Time constraints
Please provide any additional details about your refusal		This is a test
If you could be pregnant, what is your current pregnancy status?		No
I acknowledge that refusing the recommended X-ray may affect diagnosis or treatment and accept responsibility for this decision.		Disagree
I release the provider and facility from liability arising from my refusal, to the extent permitted by law.		Strongly agree
Patient or authorized representative full name (printed)		John Smith
Signature of patient or authorized representative		This is a test
Date signed		2025-10-15T00:00:00.000Z
Witness full name		John Smith
Witness signature		This is a test
Witness date		2025-10-15T00:00:00.000Z
Relationship to patient (if not self)		Legal representative
Clinician full name		John Smith
Clinician notes		This is a test
I reviewed the risks, benefits, and alternatives with the patient/representative.		Yes

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X-Ray Refusal Form Template

Simplify Patient Consent with a Professional X-Ray Refusal Form

When to use this form

Must Ask X-Ray Refusal Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

X-Ray Refusal Form Template

Simplify Patient Consent with a Professional X-Ray Refusal Form

When to use this form

Must Ask X-Ray Refusal Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results