About this template
An X-ray release form is an essential document used by medical and dental practices to gather patient details and secure formal authorization for transferring or taking diagnostic imaging. Whether a patient is switching providers, seeking a specialist consultation, or requesting copies of their own dental or medical X-rays, this form ensures the process is documented and legally sound.
Doc2Form allows healthcare offices to quickly deploy this template as a digital Google Form, making it effortless for patients to fill out details, specify destination providers, and sign online before their appointment. By streamlining intake, clinics can reduce administrative friction, minimize paperwork bottlenecks, and maintain clear records of patient consent.
This template collects all necessary patient identifiers, contact information, specific reasons for the release, and designated recipient details. Customize the questions to align with your clinic's workflow and embed the form directly into your practice website or send it via email ahead of time to save valuable chairside minutes.
Key features
- Collect patient authorization and contact details seamlessly
- Specify exact recipient providers and diagnostic record types
- Streamline intake workflows for dental and medical clinics
- Built natively on Google Forms for easy sharing and secure storage
Use cases
Patients transferring dental records to a new orthodontist or endodon…
Patients transferring dental records to a new orthodontist or endodontist
Requesting specialist review of hospital diagnostic X-rays
Providing authorized family members access to patient imaging records
What this form collects
- Full Legal Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Enter your date of birth for patient verification.
- Patient Phone Number (Short answer)Provide a reliable phone number where we can reach you if needed.
- Email Address (Short answer)Where should we send confirmation of this release request?
- Patient Mailing Address (Paragraph)Include your street address, city, state, and zip code.
- Reason for Release (Paragraph)Briefly explain why these X-rays are being requested or transferred (e.g., changing dentist, specialist referral).
- X-Ray Release Recipient (Short answer)Provide the name of the doctor, dentist, clinic, or organization receiving the records.
- Recipient Office Mailing Address & Phone (Paragraph)Provide the full address and phone number of the receiving office or practitioner.
- Authorization Date (Date)Enter today's date.
- Patient Signature / Acknowledgment (Short answer)Type your full legal name here to certify that you authorize the release of your X-ray records as specified above.
FAQ
What is an X-ray release form?
An X-ray release form is a legal and administrative document that gives a medical or dental provider permission to release diagnostic imaging records to the patient or another designated healthcare facility.
How can patients sign this form remotely?
By turning this template into a Google Form using Doc2Form, you can email or text the form link to patients so they can complete and submit it securely from their smartphone or computer before arriving.
What details are required in an X-ray release?
The form typically requires the patient's full name, contact info, the specific reason for the release, the name and address of the receiving provider, and a digital acknowledgment or signature.
Can I customize the questions on this template?
Yes! Once the template is loaded into your Google account, you can freely add, remove, or edit any fields to match your clinic's specific intake requirements.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.