PATIENT DEMOGRAPHIC FORM

Patient Demographics Form

SUN RADIOLOGY

623-815-8200

623-815-8299

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:

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: