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Consent to Obtain Medical Records

Facility records are being released from:
Facility Name*
Facility Address*
Facility City*
Facility State*
Facility Zip*
Facility Phone*
Facility Fax*
Patient Info:
Full Name*
Date of Birth*
MM slash DD slash YYYY
I authorize the release of:
Please add body part(s) images to be released*
Initials*
Medical Records
Would you like to send records on a specific injury/condition or send records on all injuries/conditions?*
- Specific injury/condition
- All injuries/conditions
Injury/Condition*
Please specify the injury or condition you would like the records sent on.
Please check the items you would like to release:
- Office Notes
Initials*
Please check the items you would like to release:
- Radiology Reports
Initials*
Please check the items you would like to release:
- Operative Notes
Initials*
Please check the items you would like to release:
- Other
What other items would you like to release?
Initials*
Specify the additional records you would like to include:
Medical Records and/or images to be sent to:

Four Seasons Imaging
17 Riverside Street, Suite 103
Nashua, NH 03062
Fax # 603.886.9838
Consent*
I give my permission for my records to be sent via mail or fax. If you do not check this box, your records will not be sent.*
Initials*
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.
Signature (Patient or Responsible Adult)*
Relationship if other than Patient
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Comments
This field is for validation purposes and should be left unchanged.

Consent to Obtain Medical Records

Medical Records

Medical Records and/or images to be sent to: