Consent to Release Diagnostic Images

Full Name*
Date of Birth*
MM slash DD slash YYYY
Street Address*
City*
State*
Zip Code*
Phone Number*
XR #
Please specify body part
- RT
- LT
Approximate date images were taken*
MM slash DD slash YYYY
Images to be picked up?*
- Yes
- No
Please choose pick-up office location*
Would you like to send your images to another physician or facility?*
- Yes
- No
Physician/Facility Info*
*
Street Address Address Line 2 City State ZIP Code
Did we refer you to the above physician or facility?
- Yes
- No
* If any charges occur for the copying of images we will contact you

** We are only able to release New Hampshire Orthopaedic Center images
Signature (Patient or responsible adult)*
Relationship if not patient