Provider Record Release Authorization

Provider Patient Record Request
Request to disclose and release confidential imaging records for below named patient.
Patient *

First NameLast Name
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Date
Records Requested:*

Dental Radiographs / PhotosCBCT / IOS Image DataRadiology / Imaging ReportsComplete Patient File
Who should receive the record(s)?*

Release records directly to meRelease records to recipients below
First NameLast Name
First Name Last Name
First NameLast Name
Dental Lab
I release Orbit Imaging from responsibility concerning the fulfillment of the release of the requested patient record.
Referring Provider*

First NameLast Name
Recipient Email*
example@example.com
Signature of Referring Provider*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Provider Patient Record Request