Simple Film Release Form

Film Release Form

X-RAY # TODAY'S DATE

PLEASE PRINT

PATIENT'S NAME __________________________

Last First

PATIENT'S DATE OF BIRTH

__________________

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_____________________________________