Patient Online Imaging Request Form

Upon completion of the following online request form, your medical imaging record will be transferred to you by Oxford Medical Imaging into a secure account maintained by PocketHealth, a third-party vendor.

Once transferred, your record will be maintained permanently within your PocketHealth account for you to access, view, download, or share with a healthcare professional. An administrative fee of $6.00 will be charged for this online request.

To learn more about PocketHealth and the functionality of the online account where your medical imaging records will be stored, please visit www.mypockethealth.com. Once you are ready, please proceed by clicking "Continue" below.

Having trouble? Call PocketHealth Support, toll-free at 1-855-381-8522.

Patient Online Imaging Request Form

①
Patient Information
②
Record Details
③
Review & Consent
④
Payment Details

Please provide the following patient information:

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

Having trouble? Call PocketHealth Support, toll-free at 1-855-381-8522.

Patient Online Imaging Request Form

①
Patient Information
②
Record Details
③
Review & Consent
④
Payment Details

Please specify the clinic you most recently visited from the menu below:


Please confirm below:


Having trouble? Call PocketHealth Support, toll-free at 1-855-381-8522.

Patient Online Imaging Request Form

①
Patient Information
②
Record Details
③
Review & Consent
④
Payment Details

Please review the Patient Information and Record Details below, and provide your signed consent below:


Patient Information

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

Record Details

Consent

I, , hereby waive all claims against Oxford Medical Imaging, its doctors, employees and agents for all purposes whatsoever in connection with said communication and disclosure of information in the said records. I understand that my records will be made available to me via a secure third-party record storage platform, PocketHealth, through which I will be able to access, view, download, and share these records at my discretion. I understand that future records, if/when they are created will also be made available to access and add to my account, at my discretion. I understand that I will be able to opt out of this online access at any time. I authorize Oxford Medical Imaging to release my records to me as I have specified within this form.

By tapping or clicking and dragging using your mouse, please provide your signature below in acknowledgement of your consent:

Reset Signature

Having trouble? Call PocketHealth Support, toll-free at 1-855-381-8522.

Patient Online Imaging Request Form

①
Patient Information
②
Record Details
③
Review & Consent
④
Payment Details

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

Having trouble? Call PocketHealth Support, toll-free at 1-855-381-8522.

Patient Online Imaging Request Form

Having trouble? Call PocketHealth Support, toll-free at 1-855-381-8522.

What is a CVC?

The CVC is a 3 or 4 digit security code, usually found on the back of your card.

Invalid Input

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