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Patient Forms
We would prefer that you to fill out your forms electronically whenever possible. We will text or email you a link to the forms 2 days before your scheduled appointment.

If you'd like to fill out the forms on paper instead, please print the relevant forms below, complete them, and bring them with you to your appointment. Please do this no earlier than one week before your appointment, since symptoms can change over time.
  Billing Policy  
  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  
  Personal Representative Form (To designate an alternate contact person if we're unable to contact you)  
Breast Imaging Patients (COMPLETE BOTH FORMS)
  Breast Imaging Billing Policy  
  Breast Imaging Questionnaire  
Other Patients (pick the appropriate tests)
  Pelvic or Obstetric Sonogram  
  Abdomen or Kidney Sonogram  
  Thyroid Sonogram  
  Osteoporosis DXA Test Billing Policy - Do not fill out this form if your insurance is Federal Medicare  
  Osteoporosis DXA Test  

Transfer of Images - if coming from or going to another imaging facility
  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 transfer your records to another facility
(This option is only if are going elsewhere for your next imaging test or your doctor needs our imaging pictures. Your doctor will automatically receive a report of your test results.)

Please give us 48-72 hours lead time to get your images ready for you.
If you'd like to email your form to us, please send it to

For your information, please refer to our list of accepted insurance plans and our privacy policy.
Copyright 2004-24  Weinstein Imaging Associates, Pittsburgh, PA       North Hills 412-630-2649  •  Shadyside 412-441-1161  •  South Hills 412-440-6999
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