X Ray Refusal Form - “i am refusing to have these radiographs taken at this time. ____________________ from any and all liability. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences.
I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. “i am refusing to have these radiographs taken at this time. ____________________ from any and all liability.
I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. “i am refusing to have these radiographs taken at this time. ____________________ from any and all liability. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent.
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____________________ from any and all liability. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. “i am refusing to have these radiographs taken at this time. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent.
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I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. “i am refusing to have these radiographs taken at this time. ____________________ from any and all liability.
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I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. ____________________ from any and all liability. “i am refusing to have these radiographs taken at this time.
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____________________ from any and all liability. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. “i am refusing to have these radiographs taken at this time. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent.
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By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. “i am refusing to have these radiographs taken at this time. ____________________ from any and all liability. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences.
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____________________ from any and all liability. “i am refusing to have these radiographs taken at this time. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent.
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____________________ from any and all liability. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. “i am refusing to have these radiographs taken at this time.
Fillable Online Dental X Ray Refusal Consent Form. Dental X Ray Refusal
____________________ from any and all liability. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. “i am refusing to have these radiographs taken at this time. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences.
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I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. ____________________ from any and all liability. “i am refusing to have these radiographs taken at this time. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent.
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“i am refusing to have these radiographs taken at this time. I am provided with this refusal form and information so i may understand the recommended treatment and the consequences. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. ____________________ from any and all liability.
I Am Provided With This Refusal Form And Information So I May Understand The Recommended Treatment And The Consequences.
____________________ from any and all liability. By signing this form, i understand that the refusal of the recommended radiographs, could result in medical risks to myself/the dependent. “i am refusing to have these radiographs taken at this time.