Patient Intake Form

Last Name

First Name

Sex

Date of Birth

Address

Parish

Postal Code

Phone (Work)

Phone (Home)

Email

Mobile

Marital Status

Employer Name

Occupation

Physician Name

Allergies or Medical Precautions

Emergency Contact

Phone

INSURANCE INFORMATION

Insurance Co. Name

Policy #

Address

Parish

Postal Code

Insurance Co. Name

Policy #

Address

Parish

Postal Code

Ensured Employer Name

This is a diagnostics test that uses sound waves to produce images of your internal organs. The benefit of this exam is to assist your physician with making a diagnosis. There may be other imaging alternatives however, your physician believes that a diagnostic ultrasound test will be the best for you, after evaluating your symptoms. Once your test is complete your physician will receive your results within 24· 48 hours after the test.

Consent

I do hereby agree and give my consent to the technologist, to perform imaging in the region of concern, that will provide a diagnostic report for the referring physician.

Results

I do here by agree and understand that the technologist will not be able to provide results at the time of test.

Charges

I do hereby understand that I am responsible for any additional charges incurred, that is not immediately covered by my insurance provider. All charges not payable between 60·90 days will accumulate a 2% interest fee.

CAPTCHA

441-261-9292

Our Services

Contacts

Opening Hours

441-261-9292