BSQ Image Request

BSQ IMAGE REQUEST - EXTERNAL PROVIDER FORM

BSQ Accession Label Here

Request For:

Electronic TransferImage/Record DVD/CD

Requesting Radiologist :

Dr Maree Kekeff - Surgeon, Gold Coast Breast Centre

Address Film/ Image copes to be sent to : Southcoast Radiology

Client Details

Date of Birth: *

Client ID:

Surname: *

Maiden Name:

Given Name *

Address: *

Reason for Copies

Investigation of concerning symptoms - GP referral attachedOther ( Please Specify) - Pre Surgery Workup

Copies Requested

All Radiology Reports/ ImagesAll Pathology ResultsScreening Film/ ImagesOther

Client Consent for Electronic Transfer / Release of Image/Record, DVD/CD

Verbal Consent Obtained

Yes

Staff Signature: ___________________________

Date: ___________________________

Patient Name *

Give Permission for my Breast Screen Queensland images/ records to be electronically transferred/ copied and released. The copy film/ images are to be released to: Southcoast Radiology / Dr Maree Kekeff - Gold Coast Breast CentreGive permission to BreastScreen Queensland to obtain results of my investigations

Date *

Client Signature *

Draw signature|Type signatureClear

Witness Signature *

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