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 help@mypockethealth.com. You may also call 1-855-381-8522 toll-free Monday - Friday, 9AM - 5PM.

Patient Information

First Name
Last Name
OHIP Number
Date of Birth: (mm/dd/yyyy)
Email
Phone Number

Study Details

Clinic Location
Study Date
Study Type

Payment Details

An administrative fee of $6.00 will apply. Please enter your payment details below:
Cardholder Name
Card Number
Card Expiry (MM/YY)
CVCWhat is a CVC?

Consent

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:
Reset Signature
After submission, your request will be verified by a clinic representative and an email from secure@mypockethealth.com 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.