X-RAY Release Form

X-RAY Release Form Template

Please fill out this form completely to authorize the release of your X-ray records.

Patient Information

Name

    Date of Birth

      Address

        Phone number

          X-Ray Information

          Date of X-Ray

            X-Ray Type

            X-Ray Taken By

            Release Authorization

            I, the undersigned, authorize the release of the X-ray(s) indicated above to:

            Name of Recipient/Doctor

              Facility/Organization

                Address

                  Phone number

                    Email (if applicable)

                      Reason for Release

                      Please check one

                        • Continued Medical Care

                        • Personal Use

                        • Insurance/Legal

                        Acknowledgment and Signature

                        I understand that by signing this form, I am authorizing the release of my X-ray(s) as specified. I confirm that I am the patient or have the legal authority to make decisions regarding the release of these records.

                        Parent/Guardian Name:

                        Relationship to Patient:

                        Date:

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