X-Ray Refusal Form


I, , request that the following proposed radiograph(s): not be taken. I realize proper diagnosis of any cavities, cysts, abscessed teeth, tumors, bone loss, or any other condition not otherwise mentioned cannot be diagnosed without these x‐rays being taken. I hereby release the attending doctor and West Grande Prairie Dental from any liability for undiagnosed conditions.


I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS/LIMITATIONS PROVIDED. I ALSO STATE THAT I READ AND WRITE IN ENGLISH, IF THIS IS NOT THE CASE I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO HAVE THIS DOCUMENT TRANSLATED FOR ME.