PocketHealth

Imaging Record Access

Secure Online Account

Upon completion of the following online request form, your medical imaging history from Main/Caledonia X-Ray & Ultrasound will be transferred to you into a secure account maintained by PocketHealth, a third-party platform.

Permanent Access

Once transferred, your record will be maintained permanently within your PocketHealth account for you to access, view, download, or share with a healthcare professional.

Transfer Fee

A transfer fee of $5.00 + HST will be charged for this request and will include all available imaging from your history at Main/Caledonia X-Ray & Ultrasound.

Learn More

Visit www.mypockethealth.com to learn more about PocketHealth and the functionality of the online account where your medical imaging records will be stored.

Imaging Record Access

1. Patient Information

Patient Information

Full Name

As it appears on your health card.

Date of Birth

/ /

OHIP Number

No OHIP Card?

-

If your health card does not have a version code (the part after the dash), please leave that part empty.

Email

Phone Number

Full Name

Date of Birth

Email

Phone Number

2. Consent

Consent

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.

Are you a delegate of the patient?

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.

Are you the patient themselves?

Delegate's Full Name

Relation to Patient

Address

Phone Number

Authorization Document

Attach file Change ×

Please provide supporting documentation affirming your status as an authorized representative of the patient. You may attach any image file or a PDF document.

Signature

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

3. Secure Payment

A transfer fee of $5.00 + HST will apply.
Please submit your payment details in the secure form below:

PocketHealth does not store your credit card information at any point in time.
This page is secured by bank-level encryption standards.

Having trouble?

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

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