X-Ray Request Form
This is to authorize
To release any information concerning
Patient Name
Date of Birth
Phone
Address
City
State
Zip
Please send digital records to
colleenolivero@verizon.net
Please transfer records prior to
Signature of Patient/Legal Guardian
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship to Patient:
X-Ray Release Form
Patient Name
Date of Birth
Phone
Address
City
State
Zip
This is to authorize the office of Thomas Olivero, Jr., DDS, PLC to release any information concerning the above patient to the following address/email:
Address
City
State
Zip
Email
Please transfer records prior to
By signing below, I understand that the above office will have access to my personal health information on file at Thomas Olivero, Jr., DDS, PLC's office to include, but not limited to, clinical notes and imaging files. I understand that my digital images/records may be sent electronically to the above email address.
Signature of Patient/Legal Guardian
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Relationship to Patient: