Imaging and Information Request Form

USE THIS FORM TO REQUEST IMAGING RESULTS / MEDICAL INFORMATION

Today's Date (required)

Client Name (required)

Therapist Name (required)

INFORMATION REQUESTED

What imaging results or information are you requesting? Please be as specific as possible.

When was the imaging performed? Please be as specific as possible.

Where was the imaging performed? Please be as specific as possible.

Additional Information

Your Message