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
Would you like images sent to your email? FASTEST*
- Yes
- No
E-Mail address required to send electronically.
Would you like to send your images to another physician or facility?*
- Yes
- No
Physician/Facility Info*
E-Mail address
*
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)*
Today's Date*
MM slash DD slash YYYY
Relationship if not patient
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