Professional Terrace Radiology
3537 West Front Street
Traverse City MI 49684
(231) 935-8962
X-RAY RELEASE
Date:
05/09/2008
To:
Re:
Patient Name:
Birth Date:
I hereby authorize you to release to
:
Professional Terrace Radiology
3537 West Front Street
Traverse City MI 49684
Information Desired:
All original mammograms and reports
Witness
Date
Signature
Date
Copyright protected. See
Registration
page.
