If patient refuses x-ray services, have patient complete the following:I, Type name (Print Name of Patient) hereby acknowledge that Dr. Type name (“Doctor”)of the Type a label (name of clinic, hereinafter referred to as “Clinic”) has recommended that I be X-rayed prior to treatment and has explained to me the reasons and need for such X-rays. Dated this Type date day of Type day , 20 Type year Patient’s Signature Signature or Signature of Authorized Representative of Patient Signature Print Name and Capacity of Authorized Type a label Representative (E.G. “Parent” or “Guardian”) Type a label
PATIENT’S STATEMENT REGARDING PREGNANCY AND RELEASE TO BE X-RAYED
If patient is female, have patient complete the following:I Type a name (Print Name of Patient) hereby acknowledge that Dr. Type a name has informed me prior to being x-rayed of the advisability of risk and the probable consequences of receiving X-Rays during pregnancy. I have stated on my own violation that I am not pregnant at this time and do hereby release and hold harmless from any legal action or responsibility caused by the use of X-Ray. Dated this Type date day of Type day , 20 Type year Patient’s Signature Signature