Seven Hills Patient Request for Release of Images and Reports

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Mammography Instructions to Patient

Please complete this document. We will retrieve your records from your previous facility for you.

Patient Instructions to Facility

Name*

First Name

Last Name

Previous Last Name - if applicable

Date of Birth*

hereby authorize:

Please release my films and reports to PowerShare to SOLIS MAMMOGRAPHY: (select the location your screening mammogram is scheduled)*

Ohio: Anderson Township– 7495 State Road, Suite 300, Cincinnati, OH 45255 (Attn: Mammography Department) PH: (513) 231-3447 F: (513) 231-3761 Ohio: Westfork Road – 3747 West Fork Road, Cincinnati, OH 45247 (Attn: Mammography Department) PH: (513) 481-4777 F: (513) 389-0473 Kentucky: Turfway – 6901 Burlington Pike, Florence, KY 41042 (Attn: Mammography Department) PH: (859) 282-6700 F: (859) 282-6760

Date:*

Patient Signature:*

[clear]

Use your mouse or finger to draw your signature above

Patient Phone Number:*

Seven Hills Women’s Health Centers Mammography Instructions to Facility

Our patient has requested the transfer of her films and reports to PowerShare to SOLIS MAMMOGRAPHY above as soon as possible for patient care purposes. Please notify us immediately if you do not have the requested films and reports.

Mammography Instructions to Patient

Please complete this document. We will retrieve your records from your previous facility for you.

Patient Instructions to Facility

Seven Hills Women’s Health Centers Mammography Instructions to Facility

Our patient has requested the transfer of her films and reports to PowerShare to SOLIS MAMMOGRAPHY above as soon as possible for patient care purposes. Please notify us immediately if you do not have the requested films and reports.

Thank you,

Seven Hills Women’s Health