I have voluntarily elected not to have diagnostic radiographs taken to help with the diagnosis and treatment planning of my dental condition. This is being done against the recommendation of my dentist, the hygienlsts, and employees.
I do not hold Happy Tooth, hygienists and /or employees liable for any failure to diagnose dental conditions, including but not limited to cavities in between teeth, oral cancer, bone loss, abscesses, cyst, infections, or any misdiagnosis due to lack of recommended xrays now or In the future. I assume full responsibility for any conditions relating to my dental or total body health that may not have been diagnosed due to lack of radiographs and accept the consequences of such refusal.
I understand that 1 may ask any questions I wish regarding the recommended treatment. It has been recommended that I have the following xray treatment, which I refuse to have: