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X-ray Request and Release Form

Date

Patient Name

Requested By (if other than patient)

Relationship to Patient

Exam Date(s) Requested

X-Ray(s) to be Sent/Faxed to

I,

authorize the release of the x-ray(s) requested above.

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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