Forms 

CLIENT

PREPARING FOR YOUR SCAN CHECKlist

Before your first consultation, please review the checklist below thoroughly. It provides the guidelines and necessary preparation steps to ensure the best possible scan for you.  

Please print and sign the Checklist, and bring it with you to your appointment.

Click here to access Checklist

Please print and complete the additional required forms below prior to your appointment.  Having this paperwork done ahead of time will greatly expedite your appointment time, and we all know how precious time is!  

Required privacy forms

• Notice of Privacy Practices

• Authorization to Use or Disclose Protected Health Information

• Request for Alternative Communications

OTHER FORMS

• Client Medical History (required)

• Client Information (required)

• Breast Questionnaires (required for breast scans)

• Full Body Study Questionnaire

• Lower Body Study Questionnaire

• Upper Body Study Questionnaire

• Women’s Health Check (required for Women’s Health Check scan)

PHYSICIAN 

• Doctor Referral Pad