X-Ray/Records Release Form

X-Ray/Records Release Form
To (Doctor Sending Records):
Address (of Doctor Sending Records):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby authorize release of my records listed below or copies of such and request that they be transmitted to inBalance Chiropractic and Wellness physicians at the above address.
Signature

Clear
Today's Date

MonthDayYear
Date
Patient Name

First NameLast Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
NOTICE OF CONFIDENTIALITY: This trransmission is intended only for the addressee(s) listed above and may contain information that is confidential and privileged. If you are not said addressee, any use, disclosure, copying or communication of the contents of this transmission is prohibited. If you have received this transmission in error, please telephone 508-425-3304 immediately. Thank you.
Should be Empty: