Consent for Disclosure of Personal Health Information

X-Ray Associates

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* 1.

Just a Reminder...

Patient Portal is a powerful tool to securely store your medical imaging information and easily share with your healthcare professionals. However, it is not intended to provide you with medical advice, and for advice about your imaging records please speak to your referring physician.
Your referring physician understands the implications of your imaging results based on your personal medical history and we advise that you always discuss your imaging records with them.

I Agree

I Disagree

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* 2. Report Access

REPORT

IMAGES

REPORT & IMAGES

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* 3. Personal Information

DATE:

FULL NAME:

OHIP NUMBER:

DOB:

ADDRESS:

CITY:

PROVINCE:

COUNTRY:

Email Address

Phone Number

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* 4. PATIENT SIGNATURE

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* 5. If the person signing is not the patient, please provide X-RAY ASSOCIATES with documentation of your authority to obtain this information.