612 W. Duarte Rd., Suite 101
Arcadia, CA 91007
Live Operator: (626) 447-0035
Scheduling (626) 445-4850

Live Operator: (626) 447-0035

Scheduling (626) 445-4850

Live Operator: (626) 447-0035

Scheduling (626) 445-4850

Forms For Patients
Forms For Patients

Patient Forms

To be best prepared, we invite our patients to download and fill out necessary forms before their scheduled appointment. Current and accurate information helps our staff tailor each patient’s exam to fit their unique needs.

Forms For Patients

Patients, download the forms below for your imaging exam.
Patient Information Form

PATIENT INFORMATION FORM

Patients, please download and fill out this form prior to coming in for your appointment. You can bring it with you or fax it to (626) 821-3460.

MRI Information Form

MRI INFORMATION FORM

MRI patients, download and complete this form prior to your appointment to save time. Bring it with you or fax it to (626) 821-3460.

Patient Questionnaire as required by the HITECH Act

PATIENT QUESTIONNAIRE

Patients visiting Arcadia Radiology will need to fill out the HITECH Act required Patient Questionnaire each time they arrive for their appointment. Bring it with you or fax it to (626) 821-3460.

Authorization for use and disclosure of protected health information form

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patients, please use this form when you wish to have your protected health information released to you or another party. You may bring this form to our office or fax it to (626) 821-3460.