Please review your inputs as some were found to contain errors. For your convenience, inputs with errors have been marked in red.
Patient Online Imaging Request Form
Your records will be made available via a secure record storage platform, PocketHealth. For any assistance in completing your request, please contact PocketHealth Patient Support at email@example.com. You may also call 1-855-381-8522 toll-free Monday - Friday, 9AM - 5PM.
Date of Birth: (mm/dd/yyyy)
An administrative fee of $6.00 will apply. Please enter your payment details below:
By signing below I attest that I am the patient identified in the form above or a legally authorized representative of that patient. I authorize Oxford Medical Imaging to release my records to me as I have specified above. I understand that my records will be made available to me via a secure record storage platform, PocketHealth, through which I will be able to access, view, download, and share these records at my discretion.
By tapping or clicking and dragging using your mouse, please draw your signature in the box below:
After submission, your request will be verified by a clinic representative and an email from firstname.lastname@example.org with a secure access link to your imaging records will be sent to within 1 business day. To learn more about PocketHealth and the functionality of the PocketHealth account where your imaging record will be stored please visit www.mypockethealth.com.
What is a CVC?
The CVC is a 3 or 4 digit security code, usually found on the back of your card.