Electronic Imaging Transfer Form

Patients Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

Reason of Request(Required)

Date of Imaging(Required)

Type of Imaging and Body Parts(Required)

Person Receiving Images(Required)

First Last

Receiving E-mail Adress(Required)

Contacts Phone Number(Required)

Contact Adress(Required)

Street Address City ZIP / Postal Code Country

Please note, the form MUST be signed in order to process the request

I confirm that, the individueal making the request, have sought the consent of the patient to release their images to the adress declared above

Please return to
Radiographers, Fortius Clinic 17
Fitzhardinge Street London
W1H 6EQ

Alternatively plase scan/photograph and email to
maryleboneradiographer@fortiusclinic.com