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Patient Registration Form
First Name
Last Name
Middle Initial
Age
Date of Scan
Phone
Date of Birth
Gender
Male
Female
Height
Weight
Mailing Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Email
Employer
Occupation/Job Title
How Long?
Personal/Primary Care Physician Name
Physician Phone
Physician Fax Number: (Please list if you want your doctor notified of scan results)
Physician Address
Physician City
Physician State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Physician Zip Code
Prescriptions will be needed for ALL scans for men under age 40 and women under age 45
If you meet this criteria, have you faxed prescription from your **physician to ViaScan at 972-739-2854 before your appointment?
Before Scheduling you were pre-screened no order needed
Yes
No
Have You Ever Had An Electron Beam Tomography (EBT) Scan Done Before?
Yes
No
If so, where and when did you have it done?
If so, would ViaScan be able to get a copy of your previous scan?
Yes
No
N/A
**Prescriptions must be completed by an MD, DO, PA, or NP
If you have prior scans, can you please bring them to your appointment?
Yes
No
If so, where and when did you have it done?
If so, would ViaScan be able to get a copy of your previous scan?
Yes
No
N/A
If you have prior scans, can you please bring them to your appointment?
Yes
No
N/A
When Was The Last Time You Had Blood Work Done?
Are You Allergic to Any Medications or Contrast Material?
Yes
No
I don't know
Patient’s Primary Concern(s):
Chest Pain or Discomfort
High Cholesterol
High Blood Pressure
Shortness of Breath
Excess or Over Weight
Tobacco/E-Cig Use
Diabetes
Sedentary Lifestyle
Family History of Heart Disease
Other
Please specify
I hereby authorize ViaScan of Las Colinas to furnish to the aforementioned referring physician any reports and/or films pertaining to services rendered or treatment given for the purpose of review or evaluation of Computerized Tomography (CT) test results. Further, if any medical documentation is required, I authorize ViaScan of Las Colinas to request this information on my behalf per the HIPPAA Guideline.
I hereby certify that all information on the form is correct and agree to the stated allegation.
Signature
Date
Extras Available (CD-ROM: $25)
Yes
No
Please initial here if you DO want us to fax the results to your doctor
Please initial here if you DO NOT want us to fax the results to your doctor
Send
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MOBILE SCAN SCHEDULER
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