PATIENT REGISTRATION INFORMATION. Patient Name. Today's Date. _____. Date of Birth. Gender. Social Security Number. Home
PATIENT REGISTRATION INFORMATION Patient Name
Today’s Date
Date of Birth
_____
Gender
Social Security Number
Home Address ____
City
_____
__________
Home Phone
State
Zip Code
Cell Phone
REFERRING PHYSICIAN:
__
RESPONSIBLE PARTY/GUARANTOR INFORMATION Name
Date of Birth
PATIENT’S RELATIONSHIP TO GUARANTOR (Please circle)
SELF
SPOUSE
CHILD
OTHER
AUTHORIZATION OF RELEASE OF MEDICAL RECORDS Patient’s Signature: ______________________________Date: _______________ I hereby authorize ____________________ __to send any Report, CD and any other medical records to THOUSAND OAKS RADIOLOGY
Date(s) of service: ___________________________________________________ Exam(s) requested: __________________________________________________ Type of Record Needed: Report Only ________ CD Only ________ Report and CD ________
Medical records are to be sent/faxed to:
Thousand Oaks Radiology 2180 Lynn Rd., Thousand Oaks, CA 91360 t. (805) 495-9442 f. (805) 496-6595
