Patient Registration Form

Please complete all fields. This information is required to process your imaging appointment.

Required — All Patients

Instructions: Complete this form and bring it to your appointment, or have it ready to hand to our front desk staff. You may also and fill it out by hand.

1. Patient Information

Last Name *

First Name *

Middle Initial

Date of Birth *

Sex at Birth *

Social Security # (last 4)

Street Address *

City *

State *

ZIP Code *

Home Phone

Cell Phone *

Email Address

Preferred Language

Marital Status

2. Referring Physician / Order Information

Referring Physician Name *

Referring Physician Phone

Exam / Study Ordered *

Appointment Date

Reason for Exam / Clinical Indication

3. Insurance Information

Primary Insurance

Insurance Company *

Member ID / Policy # *

Group Number

Policyholder Name

Policyholder Date of Birth

Relationship to Patient

Secondary Insurance (if applicable)

Insurance Company

Member ID / Policy #

Self-Pay?I do not have insurance / will pay out-of-pocket

4. Emergency Contact

Name *

Relationship *

Phone *

5. Authorization & Signature

I authorize Advanced Medical Imaging to release any information necessary to process insurance claims for services rendered. I assign benefits payable under my insurance policy to Advanced Medical Imaging. I understand that I am financially responsible for any balance not covered by my insurance. I certify that the information provided is accurate and complete to the best of my knowledge.

Patient Signature *

Sign above

Date *

If signing on behalf of patient — Print Name & Relationship

← Back to Forms