Patient Forms
For your convenience we have listed all your pre-admission paperwork for your appointment here.
These forms are interactive so you may type your information in the boxes provided and submit them to our admissions office by clicking the submit button. You may also print them off and fill them out by hand if you prefer, and bring them in with you to your appointment.
Please note you do not have to fill out every form, only the ones applying to your scheduled study. The header above each section should explain which forms apply to your visit, but if you have questions, please feel free to call 719-595-7600 for information or guidance.
Patient Forms
Forms to fill out and bring to your appointment (all patients).
Patient Information (Admit) Form
Forms to fill out to request Films or CD of prior study.
Request For Permanent Transfer of All Breast Films and Reports
Authorization of Release for Mammography Films and Reports
Authorization For Use And Disclosure Of Park West Imaging Health Information (HIPPA Authorization)
Additional forms to fill out and bring if you are a PET patient.
PET Scan Information Sheet
Additional forms to fill out and bring if you are a MRI patient.
Park West Imaging MRI Screening Form
Additional forms to fill out and bring if you are a Mammography patient.
Mammo History Information
Additional forms to fill out if you are having an enhanced CT exam.
Intravenous Contrast Media History