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The following forms have been provided for your convenience. Please note that these forms may not be the appropriate forms for all patients in all circumstances.

New patients can save time during their first appointment by completing the forms prior to their visit. Simply fill in the information requested, print, and bring the completed forms with you to your appointment.

Registration Forms:  All patients, regardless of the type of service they will receive, will need to complete the following forms:

Patient Privacy Notice

Patient Rights and Responsibilities

Patient Registration

Medical Records Release

Patient History Forms:  Please complete the following form(s) that pertain to the screening service(s) you will be receiving.

Skin Cancer Patient History

Skin Cancer Consent Form

Mammography Patient History

Diabetic Screenings Patient History

Bone Density (DEXA ) Patient History

Heart Health Screenings

 

Spanish Forms

AVISO DE PRIVACIDAD

DERECHOS PACIENTES Y RESPONSABILIDADES

INFORMACIÓN DEL PACIENTE Y RECONOCIMIENTO

CONSENTIMIENTO PARA REVELAR REGISTROS MEDICOS

FORMA HISTORIAL DEL PACIENTE – EXAMEN DE MAMOGRAFÍA

FORMA HISTORIAL DEL PACIENTE – EXAMEN DE LA DIABETES

FORMA HISTORIAL DEL PACIENTE – EXAMEN DEXA

7717 N Hartman Ln
Tucson, AZ 85743

Assured Imaging Women’s Wellness is the leading provider of mobile digital mammography in the United States. With a footprint that covers more than 60 locations across 16 states we are doing more to promote early detection of breast cancer than any other similar provider in the country.