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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 (COMPLETE ALL 3 FORMS)
  Screening for Possible COVID-19 Exposure (Please complete even if you've been vaccinated. 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 (COMPLETE BOTH FORMS)
  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.
 
 
 
Copyright 2004-21  Weinstein Imaging Associates, Pittsburgh, PA       North Hills 412-630-2649  •  Shadyside 412-441-1161  •  South Hills 412-440-6999
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