Patient 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.

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Action requested

Third Party Information

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.