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In some cases the information requested on the forms calls for medical history information, previous physicians' phone numbers, etc., which is typically easier to access with your home records nearby.
These CIVA forms are available as Acrobat files (PDFs). Just click and download the form. You can then print them out at home and fill them out at your convenience.
Your CIVA physician or nurse practitioner will advise you as to which form(s) you'll need to prepare.
New Patient Forms
New patients: to save time, please print out, complete these two forms and bring them with you to your first appointment.
Returning Patients
You will not need to complete the forms above unless there is a change in your demographics or insurance information.
Other Helpful Forms
- Confidential Information Release
- CT Scan Patient Questionnaire
- CT Angioscan Instructions
- Medical Records Release
- Patient Privacy Rights
- Instructions for Testing
Referring Physician Forms
Doctors: please complete and fax to: 214.369.6042
- Dr. Lé Consultation Referral
- Medication Records
- CT Imaging Order
- Noninvasive Lab Testing Physician Referral
You'll need the Acrobat Reader program to view these forms once you've downloaded them to your computer. If you don't have this software, you can download it free at:
http://www.adobe.com/products/acrobat/readstep2.html
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