Patient Consent form - Morton & Partners

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:

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:

Complete the below fields with the relevant information.

Patient Name and Surname *

Patient ID/Passport number *

Patient Date of birth *//

Phone *

Please use the phone number where we can contact you to verify the information (if required).

Email *

Please use the email to which you would like to the consent to be shared to.

Please select if applicable

I am a Parent, or legal guardian of the patient

STEP 2:

Please select one of the tick boxes below to either RETRIEVE your reports/images from another practice or SEND your reports/images (which was done with Morton & Partners, Centric Radiology or Kingsbury Radiology) to another practice.

RETRIEVE FROM (Our team will get your images/report from another practice for your doctor to review in our system)
SEND TO (Our team will send your images/report to another practice/organisation/doctor)

Study Requested *

Date of Study *

STEP 3:

Please complete the Third Party information so we will know where to either retrieve from or send your information.

Third Party Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Disclaimer:
By completing this document, I am allowing the third party (listed above) access to confidential patient information, including images and reports. By giving my consent, I indemnify Morton & Partners for any consequences arising from the unauthorized access of my/the patient’s images, reports and/or personal information.

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