Digital consent form

PACS digital consent

First name

Last name

Contact number

Email address

ID number

I hereby give consent to Milpark Radiology Incorporated to release my radiology images and reports to

Recipient name

Recipient email address

I take full responsibility for the use of my radiology records shared with the above-mentioned doctor/radiology/hospital. Milpark Radiology Incorporated will NOT be held liable for the illegal use of these radiology records.

Signed at

Date

Signature (In my personal capacity)

Sign Here

*Required fields

A copy of the digital consent form will be emailed to the patient’s supplied address