Weinstein Imaging Associates

More Languages

Patient Forms

Save time at our office in one of two ways:

1. PREFERRED: Click the green icon below

to submit the form ELECTRONICALLY.

2. Click the blue icon below

to PRINT the form. Fill it out and bring it with you for your appointment.

	Print Online	All Patients
		Screening for Possible COVID-19 Exposure (Do not fill out this form until it's within 24 hours of your appointment) (Encuestra para detector el riesgo de haber estado en un ambiente o contacto que pudiera resultar en infección Covid-19)
		Billing Policy
		Patient Information Form
		Breast Imaging Patients
		Breast Imaging Billing Policy
		Breast Imaging Questionnaire (Imágenes de Mama)
		Other Patients (pick the appropriate tests)
		Pelvic or Obstetric Sonogram
		Abdomen or Kidney Sonogram (Preguntas Abdominal/Renal)
		Thyroid Sonogram
		Osteoporosis DXA Test Billing Policy (Do not fill out this form if your insurance is Federal Medicare)
		Osteoporosis DXA Test
		New Patients
		Patient Information Form (If you're new to us or haven't updated the form in the past 3 yrs)
		Acknowledgement of Receipt of Notice of Privacy Practices (Reconocimiento de Recibo de Aviso de Prácticas de Privacidad)
		Personal Representative Form (To indicate whether or not you want someone else to talk to us on your behalf) - (Formulario Para Representacion Personal)
		Transfer of Images
		If you have a scheduled appointment with us AND your last similar exam was done elsewhere, fill out this form to request records (This form may be printed and faxed directly to the other facility)
		Request that we send imaging studies to another facility

For your information, please refer to our list of accepted insurance plans and our privacy policy.