Patient Consent Form - Morton & Partners Radiologists

Patient Consent
Form

Patient Consent form

Consent to Share or Retrieve Medical Records

Do you have upcoming study at a Morton & Partners Radiologists.

Please note that below form is only relevant should you require Morton & Partners Radiologists (including Centric Radiology and Kingsbury Radiology) to either RETRIEVE OR SHARE your study information (report/images) with ANOTHER practice which is not currently part of your Circle of Care.

Please complete the below Patient Image Sharing/Retrieving Consent form

I, the undersigned Patient or parent/legal guardian of the Patient (as applicable), hereby give my consent for Morton & Partners Radiologist to Send or Retrieve my / the patient’s personal medical information (images and reports) to or from the below mentioned third parties in connection with my care.

Statement of Consent:

1. I understand that the information is about me, or the patient of whom I am the parent or legal guardian (of a child, incapacitated – or elderly person).
2. I understand that the information will be sent to or retrieved from the below-mentioned third parties, as requested.
3. My consent is voluntary, and I understand that I can withdraw it at any time.
4. I understand that the information will be transferred electronically.

Step 1 of 3

STEP 1:

Complete the below fields with the relevant information.

Your Name and Surname

Passport number

Date of Birth

Please select if applicable*

I am a Parent, or legal guardian of the patient

Name and Surname

Relation

Step 3:

Please complete the below details.

Please select the practice where we can retrieve your images from

Name of third party (Doctor with whom the images must be shared)

date select third

Email of third party

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country