Consent For Release Of Medical Information (Medical Records) Page 2
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2APPROVAL BY ATTENDING CLINICIAN
Department: ___________________________________________________________________
Approved / Not Approved (Please circle)
Reason(s) for non-approval
: _____________________________________________________________________________
_____________________________________
___________________________
Name & Signature
Date
FOR X-RAY DUPLICATION ONLY (To be completed by patient requesting duplication)
I undertake to return the original X-ray film(s) to HIS through the X-ray Department
after duplication. Number of X-ray film(s) taken for duplication: _____________________
Request to duplicate X-ray film(s) from computer archive
Number of X-ray film(s) requested: ___________________________________________
Request to duplicate x-ray images on CD from computer archive
Acknowledgement by the recipient:
______________________________________
__________________________
Name & Signature of Recipient
Date
FOR RELEASE OF ORIGINAL X-RAYS (Applicable to private patients only)
Request for the original x-ray film(s) and undertake to bring them along on my next
appointment at TTSH. Number of X-ray film(s) taken: ________________________
Request to print of X-ray film(s) from computer archive
Number of X-ray film(s) printed: _________________________________________
Request to print x-ray images on CD from computer archive
Acknowledgement by the recipient:
______________________________________
__________________________
Name & Signature of Recipient
Date
* Delete where appropriate
HIS-REQ-04-04
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