Fillable Printable Simple Film Release Form

Simple Film Release Form

Film Release Form

X-RAY # TODAY'S DATE

PLEASE PRINT

PATIENT'S NAME __________________________

Last First

PATIENT'S DATE OF BIRTH

__________________

HOME PHONE ( )______________________

I am taking these X-rays to:

WORK PHONE ( )_______________________

DOCTOR __________________________________

DOCTOR'S PHONE ( )____________________

DOCTOR'S ADDRESS_________________________

CITY________________________________________

STATE____________________________________

In borrowing these original radiographs, I understand that they are the sole

property of Laurel Radiology Services, where they are maintained for my benefit.

I am aware that I am responsible for their safe return.

SIGNATURE_________________________________

RELATIONSHIP____________________________

FOR OFFICE USE ONLY

PATIENT'S LAST DATE OF SERVICE

MONTH_____________________________________

YEAR______________________________________

OFFICE_____________________________________

DATE FILMS RETURNED____________

Printed of Wed-site