Please fill out this form completely to authorize the release of your X-ray records.
I, the undersigned, authorize the release of the X-ray(s) indicated above to:
Please check one
Continued Medical Care
Personal Use
Insurance/Legal
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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