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Release for Mammography Images and Reports

I understand that by signing this form I am authorizing this facility to obtain and return any previous mammography films OR CD if needed. I also understand that should my physician, or myself, request mammography films or CD from today, according to Texas Regulation for Control of Radiation you are required to send my original films/CD. Should these films/CD not be returned to this facility within thirty (30) days, my physician or I will be responsible for storing and maintaining these films.

I, (your name) give permission for my prior MAMMOGRAPHY IMAGES and REPORT(S) to be released to:


9230 Katy Freeway, Suite 440 Houston, TX 77055

77098-3006, (713) 797-1919