Inland faculty medical group referral form

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FIND AN IMAGING CENTER

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For Patients Download Forms

DOWNLOAD FORMS

Capturing the right information is more than paperwork; it’s how we prioritize your well-being and preferences. It helps us involve, educate and respect our patients. We want to manage your appointment effectively, and we value your time and safety. You can help by printing and completing the relevant patient forms before your arrival.

Medical Record Release Form

New Patient Forms

• General Registration Form – Corona Advanced Imaging MRI/CT
• General Registration Form – Healthcare Imaging Center
• General Registration Form – Healthcare Imaging at Day Street
• General Registration Form – Moreno Valley Imaging
• General Registration Form – Corona Advanced Imaging
• General Registration Form – San Bernardino, Breast Care Imaging
• General Registration Form – San Bernardino, Redlands, Grove

CT Forms

• CT IV Contrast Informed Consent Form
• CT Patient History Form
• Virtual Colonoscopy Patient History Form

MRI Forms

• Breast MRI Informed Consent Form
• Breast MRI Patient History Form
• Breast MRI Patient Breast Implant History Form
• MRI Patient History & Consent Form

Mammography Forms

• Mammography Patient History Forms.
• Male Breast History Patient Forms.

DEXA Patient History Form

PET/CT Forms

• PET/CT Amyloid Brain-Neuro Questionnaire
• PET/CT Amyloid Brain Questionnaire
• PET/CT FDG Brain Questionnaire
• PET/CT FDG Brain-Neuro Questionnaire
• PET/CT FDG Scan Questionnaire
• PET/CT NAF Scan Questionnaire
• PET/CT NAF FDG Consent Form

Todas las formas de la lengua española

• Informacion Del Paciente – Corona Advanced Imaging MRI/CT
• Informacion Del Paciente – Healthcare Imaging Center
• Informacion Del Paciente – Healthcare Imaging at Day Street
• Informacion Del Paciente – Moreno Valley Imaging
• Informacion Del Paciente – Corona Advanced Imaging
• Consentimiento Informativo, Examen MRI Del Seno
• Historial Del Paciente De Bone Density
• Historial Del Paciente, CT
• Historial Del Paciente, Mammography
• Historial Del Paciente, MRI Del Seno
• Historial De Cirugia Del Seno, MRI Del Seno
• Historial Del Paciente, Virtual Colonoscopy
• Historial De MRI y Forma De Consentimiento
• PET/CT FDG Brain Questionnaire (Spanish)
• PET/CT FDG Brain-Neuro Questionnaire (Spanish)
• PET/CT NAF Scan Questionnaire (Spanish)
• Tarjeta de Comentarios