Steeles McLaughlin Family Dentistry
X-Ray Consent Withheld Consent Form
18-545 Steeles Avenue West, Brampton, ON, L6Y 4E7
905-455-2023
Patient's Name:
E-mail Address
Informed Refusal
I have voluntarily elected not to have diagnostic radiographs taken to help with the diagnosis and treatment planning of my dental condition. This is being done against the recommendation of my dentist.
I do not hold my dentist liable for any failure to diagnose, or any misdiagnosis due to lack of the recommended x-rays.
I assume full responsibility for any conditions relating to my dental health that may have not been diagnosed or misdiagnosed due to lack of radiographs.
Signature
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