Patient Consent for Release of Breast Images and Reports

If your last mammogram was performed somewhere other than Houston Methodist, we would like to get your images and reports.

This allows our Radiologists to compare your previous images to your new images.
By completing this form, you give Houston Methodist Sugar Land Hospital authorization to receive your images and results.

We will request your previous facility send images and reports to us prior to your appointment.

*denotes required field

Patient's First Name * Patient's Last Name * If you have gone by another First or Last Name in the last 5 years, please let us know that name Patient's Date of Birth * Email * Name of previous facility where you had a mammogram * Address of previous facility * Fax number of previous facility By checking this box and providing my full name below, I authorize the release of all breast imaging and reports to Houston Methodist Breast Care Center at Sugar Land. Electronically signed by (Full Name) *

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Patient Consent for Release of Breast Images and Reports

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