Welcome to Apex Radiology! As you prepare to have your scan completed, kindly help our team to serve you better by providing the general information requested below. Your answers will give us the information needed for your care. We are happy to answer any questions you may have in completing the form. Thank you for making us your clear choice for diagnostic imaging services.

Patient Information

Pregnancy Status

To be completed by all females up to age 55. Please tick what applies to you

If you think you may be pregnant, please inform the imaging team before the procedure

Medical History

If yes, please indicate the type and date diagnosed

Imaging History

Please list any previous imaging you have had related to this condition or others. Include dates and the type of imaging if known. Please provide any previous CD’s along with reports on the day of exam.

Surgical History

Please list all previous surgeries and dates in the table below

Procedure(s) to be Performed today

Data Protection Consent (The Data Protection Act, 2020)

By confirming this form, I acknowledge that I understand and agree to the following terms regarding the handling of my personal data:

1. My imaging results may be shared with and/or requested from other medical institutions, as well as with the medical professionals involved in my care to be used in any necessary medical reviews related to my diagnosis or treatment.
2. My medical imaging results, personal information, and health data will be securely stored and used for the purpose of diagnosis, treatment, and medical record-keeping.
3. My personal data may be used for administrative purposes, such as appointment scheduling, billing, and compliance with healthcare regulations.
4. I understand that my personal information may be processed electronically, and I consent to such processing and storage in accordance with the relevant data protection laws.

Acknowledgment and Consent

I hereby confirm that all the information provided in this document is true, accurate, and complete to the best of my knowledge.

Furthermore, I give my consent for the information provided to be used for the intended purpose and authorize the necessary actions to proceed accordingly. I acknowledge that medicine is not an exact science and that no guarantees have been made to me.

Witness Confirmation

By clicking the "Confirm" button, you acknowledge that Apex Radiology has electronically witnessed this consent form. The date and time of submission are recorded and securely stored as part of your medical record.

Disclaimer: If a procedure cannot be completed but has been attempted and instruments or inventory items used, we reserve the right to calculate the applicable refund amount, which may be less than the full amount paid for the procedure. Any monies retained would be to compensate Apex Radiology for the cost of the inventory items or costs incurred in cleaning instruments.

Apex Radiology collects and uses certain types of information about patients and individuals who interact with us. This information, whether collected on paper, stored in a computer database, or recorded on other material, is safeguarded under the Jamaica Data Protection Act 2020.