Patient Online Imaging Request Form

Upon completion of the following online request form, your medical imaging record will be transferred to you by Main/Caledonia X-Ray & Ultrasound 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 $5.00 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 select a clinic location from the menu below:


Please select from below:

Please specify the date range below. All available records within this date range will be transferred:

to

Please select study contents from 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

Please select from below:

Delegate First Name
Delegate Last Name
Relation to Patient
Address
Phone Number
Authorization
Attach file Change ×

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 $5.00 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

Please review your inputs as some were found to contain errors. For your convenience, inputs with errors have been marked in red.