Hamilton City Dental 
INFORMED REFUSAL: XRAY CONSENT WITHHELD
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. I do not hold my dentist liable for any
failure to diagnose, or any misdiagnosis due to lack of the recommended x-rays. I
assume full responsibility for any conditions relating to my dental health that may
have been diagnosed or misdiagnosed due to lack of radiographs.