NSBD - One Time Image Access Request

You will be sent a link to access Report and Images (View Only) – the link will be valid for 7 days

Requesting Practitioner Details

First Name *

Last Name *

AHPRA registration number *eg MED000XXXXXXX, CHI000XXXXXXX, PH000XXXXXXX

Email Address *

Patient Details

First Name *

Patient Last Name *

Patient Date of Birth *

Patient Studies Required (Including Body Part) *

Reason for Access *

Data Required *

Report Only Report and Images DICOM Only (security code required for image download will be forwarded separate to link)

I agree to access the requested imaging and reports only in the course of my work as a treating health professional and not for any other purpose. I also agree to keep the contents confidential and not disclose the contents to any person. I also consent to my data being collected and stored as per PRP's privacy policy. *

Date Stamp

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