{"id":49,"date":"2022-01-24T13:31:53","date_gmt":"2022-01-24T13:31:53","guid":{"rendered":"https:\/\/simonmed.wpengine.com\/?page_id=49"},"modified":"2023-07-01T09:54:42","modified_gmt":"2023-07-01T16:54:42","slug":"patient-information-form-english","status":"publish","type":"page","link":"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/","title":{"rendered":"Patient Information Form &#8211; English"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"49\" class=\"elementor elementor-49\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1064f36 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"1064f36\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-da726bf\" data-id=\"da726bf\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-51618c3f elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"51618c3f\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-18055121\" data-id=\"18055121\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6b560f3 elementor-widget elementor-widget-heading\" data-id=\"6b560f3\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Patient Information Form - English\n<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5ca7fc74 mbl-mamography elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5ca7fc74\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-578d2e27\" data-id=\"578d2e27\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e3f6c6a text-link elementor-hidden-desktop elementor-hidden-tablet elementor-widget elementor-widget-button\" data-id=\"e3f6c6a\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"\/wp-content\/uploads\/2022\/02\/Patient_Information_Form_English_updated_August_20181.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Download pdf<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-725ef55 elementor-hidden-mobile patient-print-form elementor-widget elementor-widget-html\" data-id=\"725ef55\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\n<div class=\"form-wrap\">\n\t\n\t\n\t<div class=\"center\">\n\t\t<div class=\"padding-md-h padding-xl-v shift8-padding-xs-v\">\n\t\t\t\n\t\t\t<div class=\"auth-form patient-info\" data-form=\"2018_patient_information_english\">\n\t\t\t\t\n\t\t\t\t<div class=\"error-msg\"><\/div>\n\t\t\t\t\n\t\t\t\t<form class=\"\" id=\"patient-info-form\" name=\"patient-info-form\" data-locale=\"eng\" action=\"#\" method=\"post\">\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"top-form\">\n\t\t\t\t\t\t<div class=\"col col-1\/2\">\n\t\t\t\t\t\t\t<div class=\"patient-info-image\"><img decoding=\"async\" class=\"lazy-load\" src=\"\/wp-content\/uploads\/2022\/02\/logo_withtag.png\" data-src=\"\/application\/themes\/simon_med\/img\/logo_withtag.png\" alt=\"SimonMed Logo\"><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<!-- ARRIVAL TIME -->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-1\/4 \">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"arrival-time\">Arrival Time:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"arrival-time\" id=\"arrival-time\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<!-- MRN -->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-1\/4 \">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"mrn\">MRN:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"mrn\" id=\"mrn\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t<h4 class=\"info-spacer\">\n\t\t\t\t\t\tPatient Information - PLEASE PRINT\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<!-- patient name -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-3\/4 \">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"patient-name\">Patient Name (last name, first name):<\/label>\n\t\t\t\t\t\t\t<span><input name=\"patient-name\" id=\"patient-name\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- gender -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/4 \">\n\t\t\t\t\t\t<div class=\"input-cont radio-buttons\">\n\t\t\t\t\t\t\t<div class=\"radio-cont\">\n\t\t\t\t\t\t\t\t<label>\n\t\t\t\t\t\t\t\t\t<input type=\"radio\" name=\"gender\" value=\"male\"><span>Male<\/span>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<label>\n\t\t\t\t\t\t\t\t\t<input type=\"radio\" name=\"gender\" value=\"female\"><span>Female<\/span><br>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<span class=\"spacer\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- patient name -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2 \">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"dob\">Date of Birth:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"dob\" id=\"dob\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- social security number-->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2 \">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"soc\">Social Security Number <span>(xxx-xx-xxxx)<\/span> (optional):<\/label>\n\t\t\t\t\t\t\t<span><input name=\"soc\" id=\"soc\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- address -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2 \">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"address\">Address:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"address\" id=\"address\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- city -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/4\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"city\">City:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"city\" id=\"city\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- state -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/4 selc-text \">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"\" for=\"shipping-state\">State:<\/label>\n\t\t\t\t\t\t\t<select id=\"shipping-state\" required=\"\" tabindex=\"-1\" name=\"state\" title=\"\" class=\"select2-hidden-accessible\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t<option value=\"\">--<\/option>\n\t\t\t\t\t\t\t\t<option value=\"AL\">AL<\/option>\n\t\t\t\t\t\t\t\t<option value=\"AK\">AK<\/option>\n\t\t\t\t\t\t\t\t<option value=\"AZ\">AZ<\/option>\n\t\t\t\t\t\t\t\t<option value=\"AR\">AR<\/option>\n\t\t\t\t\t\t\t\t<option value=\"CA\">CA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"CO\">CO<\/option>\n\t\t\t\t\t\t\t\t<option value=\"CT\">CT<\/option>\n\t\t\t\t\t\t\t\t<option value=\"DE\">DE<\/option>\n\t\t\t\t\t\t\t\t<option value=\"DC\">DC<\/option>\n\t\t\t\t\t\t\t\t<option value=\"FL\">FL<\/option>\n\t\t\t\t\t\t\t\t<option value=\"GA\">GA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"HI\">HI<\/option>\n\t\t\t\t\t\t\t\t<option value=\"ID\">ID<\/option>\n\t\t\t\t\t\t\t\t<option value=\"IL\">IL<\/option>\n\t\t\t\t\t\t\t\t<option value=\"IN\">IN<\/option>\n\t\t\t\t\t\t\t\t<option value=\"IA\">IA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"KS\">KS<\/option>\n\t\t\t\t\t\t\t\t<option value=\"KY\">KY<\/option>\n\t\t\t\t\t\t\t\t<option value=\"LA\">LA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"ME\">ME<\/option>\n\t\t\t\t\t\t\t\t<option value=\"MD\">MD<\/option>\n\t\t\t\t\t\t\t\t<option value=\"MA\">MA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"MI\">MI<\/option>\n\t\t\t\t\t\t\t\t<option value=\"MN\">MN<\/option>\n\t\t\t\t\t\t\t\t<option value=\"MS\">MS<\/option>\n\t\t\t\t\t\t\t\t<option value=\"MO\">MO<\/option>\n\t\t\t\t\t\t\t\t<option value=\"MT\">MT<\/option>\n\t\t\t\t\t\t\t\t<option value=\"NE\">NE<\/option>\n\t\t\t\t\t\t\t\t<option value=\"NV\">NV<\/option>\n\t\t\t\t\t\t\t\t<option value=\"NH\">NH<\/option>\n\t\t\t\t\t\t\t\t<option value=\"NJ\">NJ<\/option>\n\t\t\t\t\t\t\t\t<option value=\"NM\">NM<\/option>\n\t\t\t\t\t\t\t\t<option value=\"NY\">NY<\/option>\n\t\t\t\t\t\t\t\t<option value=\"NC\">NC<\/option>\n\t\t\t\t\t\t\t\t<option value=\"ND\">ND<\/option>\n\t\t\t\t\t\t\t\t<option value=\"OH\">OH<\/option>\n\t\t\t\t\t\t\t\t<option value=\"OK\">OK<\/option>\n\t\t\t\t\t\t\t\t<option value=\"OR\">OR<\/option>\n\t\t\t\t\t\t\t\t<option value=\"PA\">PA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"RI\">RI<\/option>\n\t\t\t\t\t\t\t\t<option value=\"SC\">SC<\/option>\n\t\t\t\t\t\t\t\t<option value=\"SD\">SD<\/option>\n\t\t\t\t\t\t\t\t<option value=\"TN\">TN<\/option>\n\t\t\t\t\t\t\t\t<option value=\"TX\">TX<\/option>\n\t\t\t\t\t\t\t\t<option value=\"UT\">UT<\/option>\n\t\t\t\t\t\t\t\t<option value=\"VT\">VT<\/option>\n\t\t\t\t\t\t\t\t<option value=\"VA\">VA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"WA\">WA<\/option>\n\t\t\t\t\t\t\t\t<option value=\"WV\">WV<\/option>\n\t\t\t\t\t\t\t\t<option value=\"WI\">WI<\/option>\n\t\t\t\t\t\t\t\t<option value=\"WY\">WY<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- zip -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"zip\">Zip Code:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"zip\" id=\"zip\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- home number -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"home-number\">Home# <span>(xxx-xxx-xxxx)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"home-number\" data-name=\"home-number\" id=\"home-number\" required=\"\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- cell number -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"cell-number\">Cell# <span>(xxx-xxx-xxxx)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"cell-number\" data-name=\"cell-number\" id=\"cell-number\" required=\"\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Email -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"email\">E-mail:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"email\" id=\"email\" required=\"\" class=\"form-control\" value=\"\" type=\"email\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- emergency contact -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"emergency-contact\">Emergency Contact:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"emergency-contact\" id=\"emergency-contact\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- emergency phone -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"emergency-phone\">Emergency Contact# <span>(xxx-xxx-xxxx)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"emergency-phone\" id=\"emergency-phone\" data-name=\"emergency phone\" required=\"\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t<h4 class=\"info-spacer\">\n\t\t\t\t\t\tMedical History\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Medication Allergies -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-full\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"allergies\">Known Allergies:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"allergies\" id=\"allergies\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Current Medication -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-full\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"current-medication\">Current Medication:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"current-medication\" id=\"current-medication\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Pregnant -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-3\/5\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\">FEMALE Patient Only: Is there a posibility you may be pregnant?<\/label>\n\t\t\t\t\t\t\t<div class=\"radio-cont\">\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"pregnant-yes\" name=\"pregnant\" value=\"yes\">\n\t\t\t\t\t\t\t\t<label class=\"radio-label\" for=\"pregnant-yes\">YES<\/label>\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"pregnant-no\" name=\"pregnant\" value=\"no\">\n\t\t\t\t\t\t\t\t<label class=\"radio-label\" for=\"pregnant-no\">NO<\/label><br>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- date of lmp -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-2\/5\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"lmp\">Date of LMP <span>(mm\/dd\/yyyy)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"lmp\" id=\"lmp\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t<h4 class=\"info-spacer\">\n\t\t\t\t\t\tInsurance \/ Workers Comp Information \/ Guarantor\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Primary Insur\/Work Comp-->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"insurance\">Primary Insur\/Work Comp:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"insurance\" id=\"insurance\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Secondary Insurance -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"sec-insurance\">Secondary Insurance:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"sec-insurance\" id=\"sec-insurance\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Date of Injury -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"date-injury\">Date Of Injury <span>(mm\/dd\/yyyy)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"date-injury\" id=\"date-injury\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Insured (Insurance) -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"insured-insurance\">Insured (Insurance):<\/label>\n\t\t\t\t\t\t\t<span><input name=\"insured-insurance\" id=\"insured-insurance\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Insured dob -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"insured-dob\">Insured DOB <span>(mm\/dd\/yyyy)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"insured-dob\" id=\"insured-dob\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Group# -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"group-number\">Group#:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"group-number\" id=\"group-number\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Member ID# -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"member-id\">Member ID#:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"member-id\" id=\"member-id\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Guarantor -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/2\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"guarantor\">Guarantor (Financially Responsible):<\/label>\n\t\t\t\t\t\t\t<span><input name=\"guarantor\" id=\"guarantor\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Guarantor dob -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"guarantor-dob\">Guar. DOB <span>(mm\/dd\/yyyy)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"guarantor-dob\" id=\"guarantor-dob\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Relation to patient -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"relation-to-patient\">Relation to Patient:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"relation-to-patient\" id=\"relation-to-patient\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Cell# -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"guarantor-cell-number\">Cell# <span>(xxx-xxx-xxxx)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"guarantor-cell-number\" id=\"guarantor-cell-number\" class=\"form-control\" value=\"\" type=\"tel\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Guarantor Address -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"guarantor-address\">Address:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"guarantor-address\" id=\"guarantor-address\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Guarantor City -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"guarantor-city\">City:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"guarantor-city\" id=\"guarantor-city\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Guarantor State -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"guarantor-state\">State:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"guarantor-state\" id=\"guarantor-state\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Guarantor Zip -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"guarantor-zipcode\">Zip Code:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"guarantor-zipcode\" id=\"guarantor-zipcode\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t<h4 class=\"info-spacer\" style=\"margin-bottom: 15px\">\n\t\t\t\t\t\tPatient's Authorized Representative\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<p class=\"reg-text\"> <strong>Please indicate with a YES or NO any authorized representative to whom we may release protected health information to, including any reports\/films, insurance and or financial information. <\/strong> <span class=\"itl-txt flt-right\">*If you are a parent or legal guardian, or have power of attorney over that patient, please list yourself below.<\/span> <\/p>\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Name-->\n\t\t\t\t\t<div class=\"form-group field field-text col col-3\/8\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"name\">Name<\/label>\n\t\t\t\t\t\t\t<span><input name=\"name\" id=\"name\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- Relationship -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-2\/8\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"relationship\">Relationship:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"relationship\" id=\"relationship\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- contact number -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-2\/8\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<label class=\"control-label\" for=\"ctc-phone\">Phone# <span>(xxx-xxx-xxxx)<\/span>:<\/label>\n\t\t\t\t\t\t\t<span><input name=\"ctc-phone\" id=\"ctc-phone\" required=\"\" data-name=\"contact number\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<!-- share records -->\n\t\t\t\t\t<div class=\"form-group field field-text col col-1\/8\">\n\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t<div class=\"radio-cont\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"share-yes\" required=\"\" name=\"share\" value=\"yes\"> <label class=\"radio-label\" for=\"share-yes\">YES<\/label>\n\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"share-no\" name=\"share\" value=\"no\"> <label class=\"radio-label\" for=\"share-no\">NO<\/label><br>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t\n\t\t\t\t\t<h4 class=\"info-spacer\">\n\t\t\t\t\t\tTelephone Consumer Protection Act Notice &amp; Other Communication\n\t\t\t\t\t\t<span class=\"flt-right\"> <i class=\"fa fa-arrow-right\"><\/i> INITIALS: _______________ <\/span>\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<p class=\"disc-txt\">In order to service your account or collect any amounts I may owe, SimonMed or its agents may contact me by telephone at any telephone number associated with my account,including without limitation wireless or cell phone numbers, which could result in a charge to me. You may also contact me using pre-recorded\/artificial voice messages and\/or through the use of automatic dialing devices. Additionally, I authorize the use of text messages and direct mail for appointment information and SimonMed promotions only.<\/p>\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t\n\t\t\t\t\t<h4 class=\"info-spacer\">\n\t\t\t\t\t\tPAYMENT POLICY\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<p class=\"disc-txt\">\n\t\t\t\t\t\tPlease review our Payment Policy, should you have any questions, we may discuss prior to your exam. <strong class=\"underlined\">Insurance:<\/strong> We participate in most insurance plans, including Medicare. If you do not have insurance or are not insured by a plan we are contracted with, payment in full is due at the time services are provided unless prior arrangements have been made and agreed to in advance. <strong class=\"underlined\">Proof of Insurance\/Referral Forms:<\/strong> We may require that you provide us with a copy of your driver\u2019s license and valid insurance card to provide proof of insurance. If  we  are  not  provided  with  the  correct  information,  you  may  be  held  responsible  for  payment.    If  you  do  not  have  your  insurance  card,  you  will  be  responsible  for payment at the time of service.  Once we obtain your insurance information, we will bill the insurance company and refund any overpayments once the claim has been paid by your insurance plan. Inform us of any insurance changes made after this signed agreement\/date of service. Insurance carriers have specific timely filing guidelines and pre-authorization requirements for certain services.  If revised insurance information is not provided to us within insurances\u2019 timely filing limits, you will be required to pay for services in full.  If prior authorization  was  required  for  services  already  received  and  your  claim  is  denied  for  lack  of  authorization,  you  will  be  required  to  pay  for  services  in  full. <strong class=\"underlined\">Co-Payments, Deductibles, &amp; Coinsurance:<\/strong>  You agree to pay all co-payments, deductibles, and co-insurance at the time your exams are performed as required by your insurance plan. A time of service payment is an estimate of the amount due. The final amount due cannot be calculated until the claim is processed by your insurance company. Additionally, the estimate of the amount due at time of service may change over time due to deductible charges processed for other medical services rendered. <strong class=\"underlined\">Non-Covered Services:<\/strong> In some instances, the services you receive may not be covered or considered medically necessary by Medicare or other insurance plans. In these instances, you will be required to pay for these services in full at the time of your exam.  Medicare patients may be required to complete a separate Advance Beneficiary Notice form in order for services to be rendered. <strong class=\"underlined\">Assignment:<\/strong> By signing this form, you agree to assign all insurance benefits to SimonMed Imaging for services performed and authorize SimonMed Imaging to submit a claim to Medicare or my insurance plan. We will submit your claim(s) to your insurance plan and will provide you with reasonable assistance to get the insurance plan to pay the claim(s). <strong class=\"underlined\">Collections:<\/strong> Once an account is placed in collection status, all future services must be paid in full at the time of service. There is a $25.00 fee for any returned checks. Patient payment policies may not be applicable in certain cases, including but not limited to workers compensation cases.\n\t\t\t\t\t<\/p>\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"info-spacer\">\n\t\t\t\t\t\tNotice of Privacy Practices &amp; Patient Rights Acknowledgement\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t<h4 class=\"disc-txt\">By my signature, I acknowledge receipt of the provider\u2019s Notice of Privacy Practices (HIPAA) and the provider\u2019s Patient Rights and have been given the opportunity to read them.<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<h4 class=\"info-spacer\">\n\t\t\t\t\t\tRelease of \/ Request for Information Authorization\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<p class=\"disc-txt\">\n\t\t\t\t\t\tSimonMed Imaging may disclose all or part of the patient\u2019s medical and\/or financial record to your insurance plan of benefit eligibility, to referring physicians, and to other healthcare providers responsible for providing continued patient care. We may request health information relating to imaging studies performed by SimonMed. This may include, but is not limited to, previous films, symptoms\/history, laboratory results, pathology reports, etc. I understand that the above listed Patient\u2019s Authorized Representative will remain valid for 1 year (or until my next appointment) whichever is sooner. SimonMed Imaging may charge a fee of up to $25.00 for each set of requested films.\n\t\t\t\t\t<\/p>\n\t\t\t\t\t\n\t\t\t\t\t<h4 class=\"info-spacer\">\n\t\t\t\t\t\tGeneral Consent and Right to Refuse Treatment\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<h4 class=\"disc-txt\">\n\t\t\t\t\t\t<strong class=\"underlined\">General  Consent  to  Treatment:<\/strong> By signing below, I (or my authorized representative on my behalf) authorize SimonMed Imaging and their staff to conduct any diagnostic examinations, tests and procedures and to provide any medications, treatment to effectively assess and maintain my health, and to assess, diagnose and treat my illness or injuries. I understand that it is the responsibility of my individual treating healthcare provider(s) to explain to me the reason(s) for any particular diagnostic examination, test or procedure, the available treatment options and the common risks and benefits associated with these options as well as alternative courses of treatment. <strong class=\"underlined\">Right to Refuse Treatment:<\/strong> In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment or medication recommended or deemed medically necessary as prescribed by my referring physician. I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as the results of my evaluation and\/or treatment.\n\t\t\t\t\t<\/h4>\n\t\t\t\t\t\n\t\t\t\t\t<p class=\"itl-txt\">\n\t\t\t\t\t\tBy signing below, I am stating that I understand and agree with the above policies and acknowledgements.\n\t\t\t\t\t<\/p>\n\t\t\t\t\t\n\t\t\t\t\t<div class=\" sign-area\">\n\t\t\t\t\t\t<!-- Patient Signature -->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-2\/3\">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"patient-sign\">Patient Signature:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"patient-sign\" id=\"patient-sign\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<!-- Sign Date-->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"sign-date\">Date <span>(mm\/dd\/yyyy)<\/span>:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"sign-date\" id=\"sign-date\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\" sign-area\">\n\t\t\t\t\t\t<!-- Patient Signature -->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-2\/3\">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"patient-sign-2\">Patient Signature:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"patient-sign-2\" id=\"patient-sign-2\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<!-- Sign Date-->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"sign-date-2\">Date <span>(mm\/dd\/yyyy)<\/span>:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"sign-date-2\" id=\"sign-date-2\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\" sign-area\">\n\t\t\t\t\t\t<!-- Patient Signature -->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-2\/3\">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"patient-sign-3\">Patient Signature:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"patient-sign-3\" id=\"patient-sign-3\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t\t\t\t<!-- Sign Date-->\n\t\t\t\t\t\t<div class=\"form-group field field-text col col-1\/3\">\n\t\t\t\t\t\t\t<div class=\"input-cont\">\n\t\t\t\t\t\t\t\t<label class=\"control-label\" for=\"sign-date-3\">Date <span>(mm\/dd\/yyyy)<\/span>:<\/label>\n\t\t\t\t\t\t\t\t<span><input name=\"sign-date-3\" id=\"sign-date-3\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"print-footer\">\n\t\t\t\t\t\t<div class=\"col col-1\/2 txt-left\">PT.CK.002<\/div>\n\t\t\t\t\t\t<div class=\"col col-1\/2 txt-right\">UPDATED: 8\/16\/2018<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"clear\"><\/div>\n\t\t\t\t\t\n\t\t\t\t\t<button class=\"call-to-action print-form elementor-button col-full\" type=\"submit\">Print Form<\/button>\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t<\/form>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7e8621db elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7e8621db\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5d6ab8f1\" data-id=\"5d6ab8f1\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-18bd6247 elementor-widget elementor-widget-image\" data-id=\"18bd6247\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-widget-image{text-align:center}.elementor-widget-image a{display:inline-block}.elementor-widget-image a img[src$=\".svg\"]{width:48px}.elementor-widget-image img{vertical-align:middle;display:inline-block}<\/style>\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"100\" height=\"52\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\" class=\"attachment-large size-large wp-image-443\" alt=\"American College of Radiology\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-2572f8a2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2572f8a2\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-7800df8d\" data-id=\"7800df8d\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-212d38b5 elementor-widget elementor-widget-heading\" data-id=\"212d38b5\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Why Choose Us<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-575164a1 elementor-widget elementor-widget-text-editor\" data-id=\"575164a1\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>SimonMed Imaging and its affiliates have been serving the community for over 30 years. Our mission is to provide best-in class affordable care through the use of advanced technology. We have patient-focused staff and highly trained medical professionals.<br \/><br \/>SimonMed has over 160 convenient locations across 11 states and provides late night and weekend appointments to accommodate patients.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-5759d4b4 img-choose-wrp elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5759d4b4\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-1dff5a4a\" data-id=\"1dff5a4a\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-27397188 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"27397188\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"86\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/radsite2.png\" class=\"attachment-medium size-medium wp-image-409\" alt=\"RadSite Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-62c159 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"62c159\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"88\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-top-doctor.png\" class=\"attachment-medium size-medium wp-image-406\" alt=\"Top Doctor Icon\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-43d8fa1a elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"43d8fa1a\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"78\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-interelated.png\" class=\"attachment-medium size-medium wp-image-407\" alt=\"Intelerad Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-39b699ce elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"39b699ce\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"81\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-sectra.png\" class=\"attachment-medium size-medium wp-image-408\" alt=\"Sectra Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-78ab54a3 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"78ab54a3\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"81\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-radsite.png\" class=\"attachment-medium size-medium wp-image-405\" alt=\"RadSite Icon\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Information Form &#8211; English Download pdf Arrival Time: MRN: Patient Information &#8211; PLEASE PRINT Patient Name (last name, first name): Male Female Date of Birth: Social Security Number (xxx-xx-xxxx) (optional): Address: City: State: &#8212;ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Home# (xxx-xxx-xxxx): Cell# (xxx-xxx-xxxx): E-mail: Emergency Contact: Emergency Contact# (xxx-xxx-xxxx): Medical History Known Allergies: Current Medication: FEMALE Patient [&hellip;]<\/p>\n","protected":false},"author":10,"featured_media":0,"parent":46,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Patient Information Form - English - SimonMed Website<\/title>\n<meta name=\"description\" content=\"patient-information-form-english\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patient Information Form - English - SimonMed Website\" \/>\n<meta property=\"og:description\" content=\"patient-information-form-english\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/\" \/>\n<meta property=\"og:site_name\" content=\"SimonMed Website\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/SimonMed\/\" \/>\n<meta property=\"article:modified_time\" content=\"2023-07-01T16:54:42+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"7 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/\",\"url\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/\",\"name\":\"Patient Information Form - English - SimonMed Website\",\"isPartOf\":{\"@id\":\"https:\/\/www.simonmed.com\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/#primaryimage\"},\"image\":{\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\",\"datePublished\":\"2022-01-24T13:31:53+00:00\",\"dateModified\":\"2023-07-01T16:54:42+00:00\",\"description\":\"patient-information-form-english\",\"breadcrumb\":{\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/\"]}]},{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/#primaryimage\",\"url\":\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\",\"contentUrl\":\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\",\"width\":100,\"height\":52,\"caption\":\"American College of Radiology\"},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-english\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/www.simonmed.com\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Patient Info\",\"item\":\"https:\/\/www.simonmed.com\/patient-info\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Patient Information Form &#8211; 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