Patient Consent — Imaging on the Velnova Health Platform

DRAFT v0.1 — 11 November 2026 — Draft for discussion. Not legal advice. To be reviewed by Nigerian legal counsel before signature or publication.

For hospitals: this template is yours to use with your patients at intake. Your hospital is the data controller; adapt the bracketed parts to your hospital before use, and file the signed copy with the patient's record.

[Hospital name and logo]

Your scan and your report — please read and sign

You are having an imaging examination (for example an X-ray, CT scan, MRI or ultrasound) at [Hospital name] ("the Hospital").

To handle your examination, the Hospital uses a secure online system called Velnova Health, provided by {{COMPANY_LEGAL_NAME}}. This form explains what happens to your information and asks for your agreement.

What happens to your information

Your images and the details of your examination are stored securely on the Velnova Health system, under the Hospital's own private area. Only authorised staff of the Hospital can see them.
A radiologist (a doctor who specialises in reading scans) will study your images and write your report. That radiologist may not be physically at this hospital — they may report from another location through the secure system. Your report is signed by that radiologist, with their name and Medical and Dental Council of Nigeria (MDCN) registration number.
Your printed report carries a verification code and a QR code. Anyone you show the report to can check it is genuine at velnovahealth.com/verify. That check shows only that the report is real, which hospital issued it, the examination, the date and the radiologist's name — never the contents of your report.
The Hospital keeps your images and reports for the period required for medical records, as explained in the Hospital's records policy. You may ask the Hospital for access to your records, or to correct anything that is wrong.

Your agreement

By signing below, I agree that:

The Hospital may store my images, examination details and report on the Velnova Health system and process them as explained above.
A radiologist reporting through the system may view my images and report on them even if they are not physically at the Hospital.
My report may carry the verification code described above.

I understand that the Hospital remains responsible for my data and my care, and that I can ask the Hospital at any time how my information is being used.

Optional: messages about your report — please tick if you agree

☐ Yes, message me. The Hospital may send me a WhatsApp or SMS message (or email) telling me when my report is ready and where to collect it. The message will contain no medical information — only that the report is ready, and the verification code. I can withdraw this agreement at any time by telling the Hospital.

Phone number for messages: ________________________________


Patient name	______________________________________________
Hospital number (if known)	______________________________________________
Signature	______________________________________________
Date	______ / ____________ / 20______ (DD Month YYYY)

If the patient cannot sign (for example, a child or an emergency), the person signing below does so as parent, guardian or next of kin:

Name: ______________________________ Relationship: ______________________________ Signature: ______________________________

Template v0.1 · 11 November 2026 · The Hospital files the signed original. A copy should be offered to the patient.