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Facility records are being released from:
I authorize the release of:
Four Seasons Imaging17 Riverside Street, Suite 103Nashua, NH 03062
Fax # 603.886.9838
I understand that this information cannot be disclosed without my written consent except as otherwise
specifically provided by law. I understand that by law, I need not to consent to the release of this
information. However, I choose to do so willingly and voluntarily for the purpose specified above.
3. I have carefully read and understand the above statements. I hereby release this practice from all legal
responsibility or liability whatsoever that may arise from the release of medical records or images
(originals or copies).
By signing below, I am verifying that all of the above information is CORRECT.