PT FORM

Patient Name

First

Last

Date of Birth

Patient Hereby Phone

Patient Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Phone

MEDICAL RECORDS INFORMATION

I Hereby Request That My Medical Records Be Released To:

Physician/Clinic's Name

Multiple Choice

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Medical Records Release Terms & Conditions

This is where we'd put your full terms and conditions for your release form. This field is marked as required and has to be ticked to be submitted.

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient's Signature

Clear Signature

Date

MEDICAL RECORDS INFORMATION

Mission

Hours of Operation

OPTIMUM IMAGING CENTER