Free X-RAY Release Form Template
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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