Patient Data Consent Form

I, the undersigned Patient or parent/legal guardian of the Patient (as applicable), hereby give my consent for Capital Radiology to Send or Retrieve my / the patient’s personal medical information (images and reports) to or from the below mentioned third parties. Statement of Consent: a.) 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). b.) I understand that the information will be sent to or retrieved from the below-mentioned third parties, as requested. c.) My consent is voluntary, and I understand that I can withdraw it at any time. d.) I understand that the information will be transferred electronically.

Name*

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Phone Number*

Email*

Message

Please attach Proof of Identification documents*

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Max. file size: 5 MB, Max. files: 2.

I hereby agree that I will not hold Capital Radiology and it's partners/affiliates accountable for any claim, damages or costs arising, directly or indirectly, from any breach of confidentiality. I further acknowledge by breaching patient confidentiality that I am breaching the POPI Act of 2013 and/or HIPAA of 1996.

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