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HOME
PATIENT CENTRE
Patient Forms
New Patient Form
Medical History Update
5-Year Medical History Update
Covid-19 Patient Screening Form
COVID-19 Pandemic Dental Risk Consent
SERVICES
Emergency Services
Emergency Dental Exams
Dental X-Rays
Cuts & Lacerations
Dental Root Canal
Dental Filling Cavities
Crowns & Bridges
Repair Broken Teeth, Fillings, Crowns & Dentures
Replacement Of Fillings & Crowns
Removal Of Foreign Bodies
Treatment Complications
Cleaning and Prevention
Complicated Tooth Extractions
Dental Restorations
Cosmetic Dentistry
Periodontal Disease
FOR STUDENTS
BLOG
News
SERVICE AREAS
Waterloo
Beechwood Waterloo Ontario
Beechwood West-Ontario
Clair Hills-Ontario
Colonial Acres-Ontario
Upper Beechwood-Ontario
View All Areas
Book An Appointment
Radiographs & X-Ray Refusal Form
Radiographs & X-Ray Refusal Form
Waterloo Emergency Dental Centre
258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505
l,
request that the following
proposed radiograph(s):
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.
Patient’s Signature
*
(Write Your Name)
Date
*
.
DD slash MM slash YYYY
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