Consent to release medical information and previous imaging

Why we need your consent:

You’ve been asked to complete a consent to release medical information and previous imaging form so Benson Radiology can obtain relevant previous imaging from another imaging provider.

Access to your previous imaging and reports may assist our team with your ongoing care.

Before we can request or access these records, we require your consent.

Please provide as much information as you can about your previous examination below.

Purpose: Benson Radiology requires access to relevant previous imaging and reports from another imaging provider. This information may assist with your ongoing care.

Before Benson Radiology can request or obtain these records, your consent is required. The information provided below will help us identify and request the relevant records from your previous imaging provider.

Patient details

First name

Last name

Maiden name (if used at the time of your examination)

Date of birth

Address

Street address

Suburb

Postcode

State

Previous imaging

Type of examination

Approximate date of examination

Imaging provider

Required information
We require the following information about the abovementioned examination:

Relevant imaging
Associated imaging report(s)
Any other relevant information relating to the examination

Please send the requested information via:
Email: modalityexpert@bensonradiology.com.au | Fax: (08) 8849 1999 | Phone enquiries: (08) 8849 1900

Patient Consent

I consent to Benson Radiology obtaining my records as they are directly involved in my ongoing care.

Signature

Date Signed

Date

Time

Patient information

Consent to release medical information and previous imaging

Why we need your consent:

Patient details

Previous imaging

Patient Consent