Patient Request for Access to Imaging Records

Patient Imaging Record Request
Patients have the right to access their personal imaging records. Please complete this form to request copies of your dental imaging and reports. Identity verification is required prior to release. Reasonable administrative or media fees may apply.
Patient Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date*

MonthDayYear
Date
Is The Patient a minor (under 19 years of age)?

YesNo
Parent / Legal Guardian / Guarantor
Full Name of Parent / Legal Guardian / Guarantor*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Patient*

ParentLegal GuardianOther (Please specify)
Please Specify
Authority to Request / Receive Records
I confirm that I am the parent or legal guardian of the minor patient named above and that I have legal authority to request and/or recieve the minor's imaging records on their behalf.
Signature of Patient (or parent or guardian if applicable)*
Date*

MonthDayYear
Date
Imaging Details
Types of Records Requested:*

Dental Radiographs / PhotosCBCT / IOS Image DataImaging ReportsAll Orbit Image Data and Reports on file
Recipient
Who should receive the record(s)?*

Release records directly to me (the patient/guarantor/ legal guardian)Release records to a third party
Delivery Method
Preferred Method of Records Release*

Secure Download Link (Patient or Third Party) - 0$USB Drive (Patient Pick Up) - 20$
Patient / Guardian Email (required for electronic delivery) *
example@example.com
Third Party Authorization
Third Party Recipient Name *

First NameLast Name
Clinic / Business Name
Recipient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Recipient Email
example@example.com
I authorize Orbit Imaging to release the records specified in this request to the recipient listed above. I understand this authorization applies only to the records requested.
Signature of Patient (or parent or guardian if applicable)*
Date*

MonthDayYear
Date
Should be Empty:

Patient Imaging Record Request

Patients have the right to access their personal imaging records. Please complete this form to request copies of your dental imaging and reports. Identity verification is required prior to release. Reasonable administrative or media fees may apply.

Patient Information

Parent / Legal Guardian / Guarantor

Authority to Request / Receive Records

Imaging Details

Recipient

Delivery Method

Third Party Authorization