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.

Please provide the following patient information:

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

Consent

Please select from below:

I, , hereby waive all claims against Main/Caledonia X-Ray & Ultrasound, 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 authorize Main/Caledonia X-Ray & Ultrasound to release my records to me as I have specified within this form.

I am a Substitute Decision Maker / Health Information Custodian of . On behalf of , I hereby waive all claims against Main/Caledonia X-Ray & Ultrasound, 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 the patient's 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 authorize Main/Caledonia X-Ray & Ultrasound to release the patient's 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: