X-Ray Refusal Form I request that the bitewing x-rays not be taken, even though such examination has been recommended by Dr. Lindsay Louwagie and associates. In so doing, I hereby release Dr. Lindsay Louwagie and associates from any responsibility for diagnosis, which should have been made if such radiographic examination had been completed. Patient's name: (please print) Signature of patient:Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
