Online Forms

In order to make your visit more convenient, we have made available forms for you to download and complete prior to arriving for your exam. Please click on the link below to open and download the form. The forms are Adobe (.PDF) format and can be opened in Adobe Reader. If you do not have Adobe on your computer you can obtain a free Adobe download from their website. Please contact us if you have any questions.

 

Patient Registration Form 

Please print this form and fill it out. When finished, you can mail or fax (805) 604-1722 the completed from to Grossman Imaging Centers. If you prefer, you may bring the completed form with you on the day of the examination.

Patient Intake Form (English & Espanol)

(Health History) Needs to be Completed prior to exam.

Patient MRI Safety Screening Form 

Needs to be Completed prior to exam.

Authorization To Release Information Form

Complete if you need to request medical records from previous outside studies.

Insurance Liability Form

Please print out form, complete and fax to us at (805) 604-1722. Bring completed form with you to your appointment.

HIPAA Authorization To Release Information Form

Physician Referral Form
Physician office may print and complete. Please fax to us at (805) 604-1722.

Physician Referral Form for PET/CT
Physician office may print and complete. Please fax to us at (805) 988-0997.


GIC Notice of Privacy Practices


GIC Confidentiality Agreement 

For questions or appointments please call:    
Main: 805.988.0616 |  Fax: 805.604.1722

© Copyright 2018 Grossman Imaging Centers