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.

  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.