RADIOLOGY INTAKE FORM

PATIENT INFORMATION:

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PATIENTS NAME:

Date:
  (LAST) (FIRST)

DOB:

Age:

SEX:

M

F

SSN:

Address:

Phone (H):
 

(W):
 

(City, State, Zip)

  

EXAM INFORMATION

Type of Exam(s):
   

Referring Physician:

2nd Physician to Receive Copy of Report:

(Name)

(Name)

(Address)

(Address)

(City, State, Zip)

(City, State, Zip)

(Phone #)

 (Phone #)

FINANCIAL INFORMATION

PAYMENT OPTIONS:

Cash

Check

Visa

 MC Amex  

EMERGENCY CONTACT:

GUARANTOR DATA:

Name:

 Name:

Relationship:

Relationship:

Phone#:

SS#:
   

DOB:

IF YOU ARE SEEING YOUR DOCTOR TODAY AND WILL BE TAKING YOUR FILMS (X-Ray, UltraSound ONLY), PLEASE SIGN THE FOLLOWING STATEMENT:

I WILL TAKE POSSESSION OF MY FILMS.      SIGNATURE:
 

IF YOU ARE NOT SEEING YOUR DOCTOR TODAY, YOUR FILMS WILL BE SENT TO YOUR PHYSICIAN AS PART OF YOUR RADIOLOGIC CONSULTATION.  YOUR PHYSICIAN WILL EITHER RETAIN YOUR FILMS OR RETURN THEM TO YOU.
 
 
 

(Radiology Employee Signature)
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