Cornerstone Health Centers — Anchored in Wellness

X-Ray Release Form

I,, hereby authorize and request the release of x-rays taken of me to:

Myself (The Patient)

Other:

Digital Copy

We require up to 72 hours from time of signature to process your request.

Please note that this form MUST be filled in fully including your signature, date, time and the Driver's License number that matches your original number originally given to the practice. Please email the completed form to cornersonehealthcenters@gmail.com

Patient/Guardian's Signature *

Sign with finger or mouse

Date & Time of Request *

Date of Birth *

Driver's License Number *

Reason for Release:

Second Opinion

Moving

Insurance Change

Not happy with Practice

Practice Portal

X Ray Release Form Cornerstone

X-Ray Release Form