Phone: (954) 966-3600. Fax: (954) 967-1962 Covid-19 Information

Download Forms

If you are a new patient, please download and print the following forms:

Patient Registration Form – (click here to download now)

Registro De Nuevo Paciente (Espanol) – (click here to download now)

Adult Health History  – (click here to download now)

CD & Film Policy Form – (click here to download now)

Financial Responsibility – (click here to download now)

Adult Health History (Espanol – click here to download now)

CD & Film Policy Form (Espanol – click here to download now)

Financial Responsibility (Espanol – click here to download now)

If you are a returning patient, please download and print the following forms:

Returning Patient Registration Form – (click here to download now)

Adult Health History  – (click here to download now)

CD & Film Policy Form – (click here to download now)

Financial Responsibility – (click here to download now)

Adult Health History (Espanol – click here to download now)

CD & Film Policy Form (Espanol – click here to download now)

Financial Responsibility (Espanol – click here to download now)

If you have been in an accident or a slip/fall, please download and print the following form:

PIP Initial Treatment or Service Form – (click here to download now)

If you or your referring provider would like a copy (ies) of your report and/or a CD of your studies, please download and print the following:

Medical Records Release Form – (click here to print and download now)

If you would like a copy of our privacy practices, please download and print the following information:

Privacy Practices – (click here to download now)

IF YOU ARE SCHEDULED FOR A MAMMOGRAM, please download and print the following form:

Mammography Questionnaire (English) – (click here to download now)
Mammography Questionnaire (Spanish) – (click here to download now)

IF YOU ARE SCHEDULED FOR A BONE DENSITY EXAM (DEXA), please download and print the following form:

Dexa questionnaire – (click here to download now)
English English Spanish Spanish