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The X-Ray Release Form is a critical document used across Canadian healthcare facilities to ensure legal compliance and patient safety in medical imaging procedures. This form is required whenever a patient undergoes X-ray examination, serving multiple purposes: documenting informed consent, acknowledging radiation exposure risks, protecting healthcare provider liability, and ensuring compliance with Canadian privacy laws and medical regulations. The document must align with provincial Health Information Acts, PIPEDA, and the Radiation Emitting Devices Act. It's particularly important in both routine medical procedures and specific situations such as workplace injuries, insurance claims, or legal proceedings where X-ray documentation is required.

1. Patient Information: Patient's full name, date of birth, contact information, and medical record number

2. Facility Information: Name and address of the medical facility, department, and healthcare provider

3. Purpose of X-Ray: Description of the type of X-ray examination and medical reason for the procedure

4. Informed Consent: Statement confirming that the procedure, its purposes, and potential risks have been explained to and understood by the patient

5. Risk Acknowledgment: Description of potential risks associated with X-ray exposure and patient acknowledgment of these risks

6. Privacy Statement: Information about how the X-ray images and related medical information will be used, stored, and protected

7. Authorization: Patient's explicit permission for the procedure and sharing of results with specified healthcare providers

8. Signatures: Dated signatures of patient (or legal guardian), witness, and healthcare provider