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Patient Forms

One or more of the following forms may be needed prior to your procedure or if you are picking up medical records/films.  If you are not sure which form(s) you need to complete, please call 719-776-5135.

Complete, print and bring the following form to your appointment if you plan on having any invasive procedure including: biopsy, CAT Scan with contrast, diagnostic joint injections/IVP, barium studies
Outpatient Medication Reconciliation

If you plan on having a CT, Nuclear Medicine exam, or diagnostic radiology procedure (Video and Barium Swallows, Esophagrams, Bone Surveys, IVP Urography, Joint Injections,etc) please complete, print and bring the following form to your appointment..

Patient Medical History Form

If you are picking up medical records or films on behalf of another person, complete, print and bring the following form, along with your and the patient’s photo ID, to the Radiology Department at Penrose Hospital or St. Francis Medical Center.
Patient Authorization to Disclose Protected Health Information

If you are picking up medical records or films for yourself or for a minor (you must be the minor’s legal guardian), complete, print and bring the following form to the Radiology Department at Penrose Hospital or St. Francis Medical Center.
Patient Request to Access Medical Records Form

 

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