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RAY REQUEST AND RELEASE FORM Date: / / Patient Name(s) Requested by (if other than the pt.) Relationship to Patient: Ray(s) to be sent to : Jennifer Sikorsky D.M.D., PA. 6100 Day Long Lane Suite 105

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How to fill out x-ray request and release

01

Step 1: Obtain the x-ray request and release form from the healthcare provider or hospital.

02

Step 2: Read the form carefully and fill in all the required information, such as your personal details (name, date of birth, address), the reason for the x-ray, and any relevant medical history.

03

Step 3: Make sure to sign and date the form at the designated areas.

04

Step 4: If there are any specific instructions provided by the healthcare provider, follow them accordingly.

05

Step 5: Once you have completed filling out the form, return it to the healthcare provider or hospital where you received it.

06

Step 6: If there are any fees associated with the x-ray request and release, ensure that they are paid as per the instructions provided.

Who needs x-ray request and release?

01

Individuals who require an x-ray for medical diagnostic purposes need to fill out the x-ray request and release form.

02

Patients who have been referred by their primary healthcare provider or specialist for further investigation through x-ray may need to complete this form.

03

Hospitals, clinics, and healthcare facilities may also require patients to fill out this form before conducting any x-ray procedures.

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