• Pediatric Dentistry




  • Date Format: MM slash DD slash YYYY
  • Required to send the filled forms to you.
  • I was informed of the need for diagnostic x-rays.I have voluntarily elected not to have this diagnostic procedure performed. This is being done against the recommendations of the above named attending dentist. I do not hold the above named dentist liable for any failure to diagnose or any misdiagnoses due to the lack of the recommended x-rays.

    I assume full responsibility for any conditions relating to my childs dental health that may have been diagnosed had the recommended x-rays been taken.

    By signing, I understand that I am authorizing The Little Teeth Workshop not to do x-rays on my child.