The X Rays Request Form is a tool used to help medical professionals request X rays for their patients. The form is easy to use and can be filled out quickly. The form includes all the information needed to order an X ray, including the patient's name, date of birth, and contact information. The form is available online or as a PDF download.
Below, you'll see quite a few specifics of x rays request form PDF. It's a good idea that you read this information before you begin working with the file.
| Question | Answer |
|---|---|
| Form Name | X Rays Request Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dental x ray release form template, x ray release form dental, authorization to release x rays, xray release form |
Date: ____/____/____
Patient Name: _____________________________________
Requested by (if other then the patient): _______________________________________
Relationship to Patient: _______________________
Exam Date(s) Requested: ___________________________________________________
________________________________________________________________________
I __________________________ authorize the release of the
________________________________________________________________________
Signature |
Date |