• Radiographs & X-Ray Refusal Form

    Waterloo Emergency Dental Centre

    258 King Street North, Unit #7,
    Waterloo, Ontario, Canada N2J 2Y9
    Phone: (519) 883-0505

  • request that the following
  • not be taken, even though such examination has been recommended by my doctor. In so doing, I hereby release the attending doctor from any responsibility for diagnosis, which should have been made if such radiographic examination had been completed.
  • (Write Your Name)
  • .
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