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. In so doing, I hereby release Dr. Osih 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 Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
