X-Ray Release Form
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1Receipt of X-Rays and/or Records
Patient Name
Date
Account #:
Doctor Name and
Address
I hereby state that I have requested the release of the medical x-ray films and/or other records of
which are currently the part of the patient
records files held by
I acknowledge the receipt of the aforementioned records and associated documents, and I fully discharge
from any liability that my arise as a
consequence of their release.
Signature:
Printed
Name:
Witnessed
By:
Printed
Name:
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