Welcome to Sunradiology

PATIENT DEMOGRAPHIC FORM

Last Name

Middle Name

First Name

Date Of Birth

Social Security Number

Race

Address

City

State

Zip

Phone Number

Alternative Phone Number

Email ID

Emergency Contact:

Name

Relationship

Phone

Release of Medical Information:

I hereby authorize Sun Radiology to send or discuss my test results and other health related information on my behalf with the following individuals:

Name

Relationship

Phone
Name

Relationship

Phone

I also authorize Sun Radiology to send or receive my medical information to other providers requesting the information.
I authorize Sun Radiology to leave detail message via email, text message or voice mail about my appointments(current & future),lab and imaging results and other health related information.
I will notify Sun Radiology if there are any updates to above information.
I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Sun Radiology P.C. notice of privacy practices. I understand that Sun Radiology participates in health current, Arizona’s health information exchange(HIE).I understand that my health information may be securely shared through the HIE unless I complete and return the Opt Out form to Sun Radiology.

Patient Signature:

Signed on: