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PATIENT IMAGING REQUEST

Patient First Name *

Patient Last Name *

Guardian First Name(If patient is under 18 years old)

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Patient Email Address

Phone Number *

ID Number *0 / 100

Date of examination

Department where x-rays were taken *

Permission

Hereby give Drs. van Rensburg and Partners SA Inc. permission to distribute my medical records to the indicated destination.

Email Address 1 *

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Please indicate the desired format of the images required *DICOMJPEGReports onlyElectronic link

Additional notes0 / 180

Please attach a copy of the patient’s ID or driver’s licence

No file chosen

Consent *

I hereby indemnify Drs. van Rensburg and Partners SA Inc. and do not hold them accountable for any claim, damages or costs arising, directly or indirectly, from the breach of confidentiality. I further acknowledge that by breaching patient confidentiality, I am breaching the POPI Act of 2013. By signing this form, I accept the terms and conditions of our client consent agreement and Data protection policy which outlines the processing of your data which is available/can be viewed at Radmin (Pty) Ltd. or any Drs. van Rensburg and Partners SA Inc. office or at www.vrprad.co.za .

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