Image Release Form

Image Release Form

Please fill out the following form in its entirety for release of your imaging study. Your request will not be processed until payment is made.

Patient pick-up $5

Mail to patient $10

After submitting the form, please call 301-777-3522 ext 125 to provide payment. Once payment is received, we will complete your request within 48 hours.

First Name

Last Name

Date of birth

Phone

Method of Delivery

Pick up ($5 per disc)Mail ($10 per disc)

Authorized pick-up person:

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country