Patient Forms

AIC Prep Instructions -

NOW OPEN 7AM – 7 PM MON – FRI FOR ALL SERVICES BY APPOINTMENT ONLY (EXCEPT ULTRASOUND)

Download PDF New Prep Instructions and Map (File size: 626,335 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

New Script Pad

Download PDF AIC script 2018 (File size: 1,449,809 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

MRI Patient Form

Download PDF mri and hippa pdf (File size: 407,180 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

New Patient Form

Download PDF New Patient Form Page 1 (File size: 225,923 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

Dexa Form

Download PDF DEXA FORM (File size: 230,680 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

X-Ray Form

Download PDF XRAY FORM 18 (File size: 227,645 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

CT/PET Form

Download PDF CT Questionnaire 18 (File size: 228,314 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

Auto Accident/Slip and Fall Paperwork

Download PDF PIP PAPERWORK WITH MCW AND ABN (File size: 595,801 bytes) Note: The request form is in PDF format and requires Adobe Acrobat Reader. If you don't have Acrobat Reader you can download it from www.adobe.com.

If you are unsure what to print, call 312-307-0938 and Vanessa will be more than happy to assist you. If calling is not convenient, e-mail her at Vanessa.vitale@advancedimagingconcepts.com