Ray Request Details

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.

QuestionAnswer
Form NameX Rays Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdental x ray release form template, x ray release form dental, authorization to release x rays, xray release form

Form Preview Example

X-RAY REQUEST AND RELEASE FORM

Date: ____/____/____

Patient Name: _____________________________________

Requested by (if other then the patient): _______________________________________

Relationship to Patient: _______________________

Exam Date(s) Requested: ___________________________________________________

X-Ray(s) to be Sent/Faxed to: _______________________________________________

________________________________________________________________________

I __________________________ authorize the release of the X-Rays(s) requested above.

________________________________________________________________________

Signature

Date