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https://www.theformteam.com/Coliseum/NewPatient-1.html
Submission: On November 27 via manual from US — Scanned from DE
Submission: On November 27 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: NewPatient-1 — POST https://secure.highlandwebforms.com/perl/post/18146-23652-3bsJ
<form id="NewPatient-1" action="https://secure.highlandwebforms.com/perl/post/18146-23652-3bsJ" method="post" name="NewPatient-1">
<fieldset>
<div style="width: 100%;">
<img class="dsR1" src="_images/logo.png" alt="Coliseum Imaging Center" border="0"><br>
<h1 align="center">Patient Information Form</h1>
</div>
</fieldset>
<fieldset>
<legend>Patient Information</legend>
<div id="field"><label for="LastName"> <b>Last Name <span class="ds2">*</span> </b><br>
<input type="text" name="LastName" id="LastName" maxlength="24" class="dsR24" required="" onchange="duplicateLN()"></label>
</div>
<div id="fieldset"><label for="FirstName"><b>First Name <span class="ds2">*</span> </b><br>
<input type="text" name="FirstName" id="FirstName" maxlength="24" class="dsR24" required="" onchange="duplicateFN()"></label>
</div>
<div id="fieldset"><label for="MI"> <b>MI </b><br>
<input type="text" name="MI" id="MI" maxlength="3" class="dsR3"></label>
</div>
<div id="field"><label for="Address"><b>Address <span class="ds2">*</span> </b><br>
<input type="text" name="Address" id="Address" maxlength="40" class="dsR40" required=""></label>
</div>
<div id="fieldset"><label for="AptNo"> <b>Apt. No. </b><br>
<input type="text" name="AptNo" id="AptNo" maxlength="6" class="dsR6"></label>
</div>
<div id="fieldset"><label for="City"><b>City <span class="ds2">*</span> </b><br>
<input type="text" name="City" id="City" maxlength="24" class="dsR24" required=""></label>
</div>
<div id="fieldset"><label for="State"><b>State <span class="ds2">*</span> </b><br>
<input type="text" name="State" id="State" maxlength="3" class="dsR3" required=""></label>
</div>
<div id="fieldset"><label for="Zip"><b>Zip <span class="ds2">*</span> </b><br>
<input type="text" name="Zip" id="Zip" maxlength="6" class="dsR6" required=""></label>
</div>
<div id="field"><label for="DOB"><b>Date of Birth <span class="ds2">*</span> </b><br>
<input type="text" name="DOB" id="DOB" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy" required="" onchange="duplicateD()"></label>
</div>
<div id="fieldset"><br> <input type="checkbox" name="Underage" id="Underage" value="checked" onclick="javascript:yesnoCheck1a();"><label for="Underage">Under age 18? </label><br>
</div>
<div id="fieldset"><label for="SSN"><b>Social Security No. </b><br>
<input type="text" name="SSN" id="SSN" class="dsR12 maskField" mask="999-99-9999" placeholder="xxx-xx-xxxx"></label>
</div>
<div id="field"><label for="Phone"><b>Phone <span class="ds2">*</span> </b><br>
<input type="tel" name="Phone" id="Phone" class="dsR14 maskField" mask="999-999-9999" placeholder="xxx-xxx-xxxx" required=""></label>
</div>
<div id="fieldset"><label for="Email"><b>Email <span class="ds2">*</span> </b><br>
<input type="email" name="Email" id="Email" maxlength="40" class="dsR40" required=""></label>
</div>
<div id="field"><b>Marital Status </b><br>
<input type="radio" name="Marital" value="MaritalSingle" id="MaritalSingle" x-sel="{{Marital}}"><label for="MaritalSingle">Single </label>
<input type="radio" name="Marital" value="MaritalMarried" id="MaritalMarried" x-sel="{{Marital}}"><label for="MaritalMarried">Married </label>
</div>
<div id="fieldset"><b>Sex </b><br>
<input type="radio" name="Sex" value="SexMale" id="SexMale" x-sel="{{Sex}}"><label for="SexMale">Male </label>
<input type="radio" name="Sex" value="SexFemale" id="SexFemale" x-sel="{{Sex}}"><label for="SexFemale">Female </label>
</div>
<div id="fieldset"><label for="Employer"> <b>Employer </b><br>
<input type="text" name="Employer" id="Employer" maxlength="40" class="dsR40"></label>
</div>
<div id="field"><label for="Contact"><b>Emergency Contact <span class="ds2">*</span> </b><br>
<input type="text" name="Contact" id="Contact" maxlength="40" class="dsR40" required=""></label>
</div>
<div id="fieldset"><label for="ContactPhone"><b>Contact Phone <span class="ds2">*</span> </b><br>
<input type="tel" name="ContactPhone" id="ContactPhone" class="dsR14 maskField" mask="999-999-9999" placeholder="xxx-xxx-xxxx" required=""></label>
</div>
<div id="YesUnderage" style="display:none">
<div id="field"><label for="GuardianName"> <b>Guardian Name <span class="ds2">*</span> </b><br>
<input type="text" name="GuardianName" id="GuardianName" maxlength="40" class="dsR40"></label>
</div>
<div id="fieldset"><label for="GuardianDOB"><b>Guardian Date of Birth <span class="ds2">*</span> </b><br>
<input type="text" name="GuardianDOB" id="GuardianDOB" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
<div id="field">
<b>Signature of Legal Guardian</b> – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
</div>
<div id="field">
<script type="text/javascript">
patientsignature = new sform.Signature({
id: 'inksig1',
form_name: 'NewPatient-1',
field_name: 'guardiansignature',
caption: 'Signature',
w: 400,
h: 75,
bg: '#E4E4E4'
});
</script>
<div id="inksig1" class="sform_sig"><input type="hidden" name="guardiansignature_sfs" value="937853,400,75,#E4E4E4,black"><input type="hidden" name="guardiansignature" value=""><input type="hidden" name="guardiansignature_file"
value="guardiansignature"><input type="hidden" name="guardiansignature_caption" value="Signature"><canvas id="inksig1_canvas" width="400" height="75" style="cursor:pointer;background-color:#E4E4E4" onmousedown="sform.od(event,'inksig1');"
onmouseup="sform.ou(event,'inksig1');" onmousemove="sform.om(event,'inksig1');" ontouchstart="sform.od(event,'inksig1');" ontouchend="sform.ou(event,'inksig1');" ontouchmove="sform.om(event,'inksig1');">Your web browser does not support
HTML5 Canvas. Signature object cannot be displayed.</canvas></div>
</div>
</div>
</fieldset>
<fieldset>
<legend>Payment Information</legend>
<div id="field">
<b>Which of the following apply to this visit? <span class="ds2">*</span> </b><br>
<input type="radio" name="Payment" value="PaymentInsurance" id="PaymentInsurance" x-sel="{{Payment}}" onclick="javascript:yesnoCheck2a();"><label for="PaymentInsurance">I have healthcare insurance </label><br>
<input type="radio" name="Payment" value="PaymentSelfPay" id="PaymentSelfPay" x-sel="{{Payment}}" onclick="javascript:yesnoCheck2a();"><label for="PaymentSelfPay">I will self-pay </label><br>
<input type="radio" name="Payment" value="PaymentWork" id="PaymentWork" x-sel="{{Payment}}" onclick="javascript:yesnoCheck2a();"><label for="PaymentWork">This is a work-related injury </label><br>
<input type="radio" name="Payment" value="PaymentVehicle" id="PaymentVehicle" x-sel="{{Payment}}" onclick="javascript:yesnoCheck2a();"><label for="PaymentVehicle">This is a motor vehicle-related injury </label>
</div>
<div id="YesInsurance" style="display:none">
<div id="field"><label for="Primary"><b>Primary Insurance Carrier <span class="ds2">*</span> </b><br>
<input type="text" name="Primary" id="Primary" maxlength="40" class="dsR40"></label>
</div>
<div id="fieldset"><label for="Secondary"> <b>Secondary Insurance Carrier </b><br>
<input type="text" name="Secondary" id="Secondary" maxlength="40" class="dsR40"></label>
</div>
</div>
<div id="YesWork" style="display:none">
<div id="field"><i>Please Complete for all Workers Compensation Claims</i><br></div>
<div style="clear:both;"></div>
<div id="field"><label for="WorkerDate"><b>Date of Injury <span class="ds2">*</span> </b><br>
<input type="text" name="WorkerDate" id="WorkerDate" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
<div id="fieldset"><label for="WorkerCause"><b>Cause of Injury <span class="ds2">*</span> </b><br>
<input type="text" name="WorkerCause" id="WorkerCause" maxlength="40" class="dsR40"></label>
</div>
<div id="field"><label for="WorkerEmployer"><b>Employer at Time of Injury <span class="ds2">*</span> </b><br>
<input type="text" name="WorkerEmployer" id="WorkerEmployer" maxlength="40" class="dsR40"></label>
</div>
<div id="fieldset"><label for="WorkerClaim"><b>Claim No. (if known) </b><br>
<input type="text" name="WorkerClaim" id="WorkerClaim" maxlength="24" class="dsR24"></label>
</div>
</div>
<div id="YesVehicle" style="display:none">
<div id="field"><label for="VehicleDate"><b>Date of Injury <span class="ds2">*</span> </b><br>
<input type="text" name="VehicleDate" id="VehicleDate" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
<div id="fieldset"><label for="VehicleClaim"><b>Claim No. (if known) </b><br>
<input type="text" name="VehicleClaim" id="VehicleClaim" maxlength="24" class="dsR24"></label>
</div>
<div id="field"><label for="VehicleInsurance"><b>Motor Vehicle Insurance <span class="ds2">*</span> </b><br>
<input type="text" name="VehicleInsurance" id="VehicleInsurance" maxlength="40" class="dsR40"></label>
</div>
</div>
</fieldset>
<fieldset>
<legend>Patients please read and sign below</legend>
<div id="field">
<span class="ds1"><b>Benefit Agreement</b><br>
</span>
</div>
<div id="boilerplate"> I request that payment of authorized Benefits Coordination be made on my behalf to Coliseum Imaging for any services furnished me. I authorize any holder of medical information about me to release to the health care
financing administration or my insurance company/agents any information needed to determine benefits payable for related services. A copy of this signature is as valid as the original. As a courtesy to you, we can file a claim to your insurance
carrier/payor/attorney. Insurance Providers/Payors may deem this test medically unnecessary and there is no guarantee of benefits. By signing this form, I understand that I am financially responsible for any and all remaining balances. </div>
<div id="field">
<b>Authorized Signature</b> – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
</div>
<div id="field">
<script type="text/javascript">
patientsignature = new sform.Signature({
id: 'inksig2',
form_name: 'NewPatient-1',
field_name: 'benefitsignature',
caption: 'Signature',
w: 400,
h: 75,
bg: '#E4E4E4'
});
</script>
<div id="inksig2" class="sform_sig"><input type="hidden" name="benefitsignature_sfs" value="937853,400,75,#E4E4E4,black"><input type="hidden" name="benefitsignature" value=""><input type="hidden" name="benefitsignature_file"
value="benefitsignature"><input type="hidden" name="benefitsignature_caption" value="Signature"><canvas id="inksig2_canvas" width="400" height="75" style="cursor:pointer;background-color:#E4E4E4" onmousedown="sform.od(event,'inksig2');"
onmouseup="sform.ou(event,'inksig2');" onmousemove="sform.om(event,'inksig2');" ontouchstart="sform.od(event,'inksig2');" ontouchend="sform.ou(event,'inksig2');" ontouchmove="sform.om(event,'inksig2');">Your web browser does not support
HTML5 Canvas. Signature object cannot be displayed.</canvas></div>
</div>
<div id="fieldset" style="padding-left: 20px;"><label for="DateSigned1"><b>Date </b><br>
<input type="text" name="DateSigned1" id="DateSigned1" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
<div style="clear:both;"></div>
<div align="center">
<b>Please help us by following up with your insurance company for any unpaid claims</b>
</div>
<div style="clear:both;">
<hr>
</div>
<div id="field">
<span class="ds1"><b>Notice of Intent to Protect Privacy (HIPAA)</b><br>
</span>
</div>
<div id="boilerplate"> The department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. This rule requires providers to obtain patient consent to use their
healthcare information for treatment, payment or other healthcare operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We also
want you to know that we support your full access to your personal medical records. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse
to treat you should you choose to refuse to disclose your Protected Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that
have already been taken which relied on this or a previously signed consent. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.<br><br> I hereby
authorize the release of all or any portion of my medical records to any health care practitioner or facility designated by me. </div>
<div id="field">
<b>Authorized Signature</b> – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
</div>
<div id="field">
<script type="text/javascript">
patientsignature = new sform.Signature({
id: 'inksig3',
form_name: 'NewPatient-1',
field_name: 'hipaasignature',
caption: 'Signature',
w: 400,
h: 75,
bg: '#E4E4E4'
});
</script>
<div id="inksig3" class="sform_sig"><input type="hidden" name="hipaasignature_sfs" value="937853,400,75,#E4E4E4,black"><input type="hidden" name="hipaasignature" value=""><input type="hidden" name="hipaasignature_file"
value="hipaasignature"><input type="hidden" name="hipaasignature_caption" value="Signature"><canvas id="inksig3_canvas" width="400" height="75" style="cursor:pointer;background-color:#E4E4E4" onmousedown="sform.od(event,'inksig3');"
onmouseup="sform.ou(event,'inksig3');" onmousemove="sform.om(event,'inksig3');" ontouchstart="sform.od(event,'inksig3');" ontouchend="sform.ou(event,'inksig3');" ontouchmove="sform.om(event,'inksig3');">Your web browser does not support
HTML5 Canvas. Signature object cannot be displayed.</canvas></div>
</div>
<div id="fieldset" style="padding-left: 20px;"><label for="DateSigned2"><b>Date </b><br>
<input type="text" name="DateSigned2" id="DateSigned2" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
<div style="clear:both;"></div>
<div id="field"><b>Name of person, if any, that you give permission to have access to your medical/billing records.</b><br>
</div>
<div id="field"><label for="AccessName"> <b>Name </b><br>
<input type="text" name="AccessName" id="AccessName" maxlength="40" class="dsR40"></label>
</div>
<div id="fieldset"><label for="AccessRelationship"> <b>Relationship </b><br>
<input type="text" name="AccessRelationship" id="AccessRelationship" maxlength="24" class="dsR24"></label>
</div>
<div style="clear:both;">
<hr>
</div>
<div id="field">
<span class="ds1"><b>Patient Feedback Consent</b><br>
</span>
</div>
<div id="boilerplate"> Coliseum Imaging Center is committed to providing the best possible patient experience and values your feedback. By signing below you hereby authorize Coliseum Imaging Center to send you a one-time text message to rate your
experience and provide an opportunity to share feedback. </div>
<div id="field">
<b>Authorized Signature</b> – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
</div>
<div id="field">
<script type="text/javascript">
patientsignature = new sform.Signature({
id: 'inksig4',
form_name: 'NewPatient-1',
field_name: 'feedbacksignature',
caption: 'Signature',
w: 400,
h: 75,
bg: '#E4E4E4'
});
</script>
<div id="inksig4" class="sform_sig"><input type="hidden" name="feedbacksignature_sfs" value="937853,400,75,#E4E4E4,black"><input type="hidden" name="feedbacksignature" value=""><input type="hidden" name="feedbacksignature_file"
value="feedbacksignature"><input type="hidden" name="feedbacksignature_caption" value="Signature"><canvas id="inksig4_canvas" width="400" height="75" style="cursor:pointer;background-color:#E4E4E4" onmousedown="sform.od(event,'inksig4');"
onmouseup="sform.ou(event,'inksig4');" onmousemove="sform.om(event,'inksig4');" ontouchstart="sform.od(event,'inksig4');" ontouchend="sform.ou(event,'inksig4');" ontouchmove="sform.om(event,'inksig4');">Your web browser does not support
HTML5 Canvas. Signature object cannot be displayed.</canvas></div>
</div>
<div id="fieldset" style="padding-left: 20px;"><label for="DateSigned3"><b>Date </b><br>
<input type="text" name="DateSigned3" id="DateSigned3" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
</fieldset>
<fieldset>
<div style="width: 100%;">
<img class="dsR1" src="https://www.theformteam.com/Coliseum/_images/logo.png" alt="Coliseum Imaging Center" border="0"><br>
<h1 align="center">MRI Screening Form</h1>
</div>
</fieldset>
<fieldset>
<legend>Patient Information</legend>
<div id="field"><label for="LastName2"> <b>Last name <span class="ds2">*</span> </b><br>
<input type="text" name="LastName2" id="LastName2" maxlength="24" class="dsR24" required=""></label>
</div>
<div id="fieldset"><label for="FirstName2"> <b>First name <span class="ds2">*</span> </b><br>
<input type="text" name="FirstName2" id="FirstName2" maxlength="24" class="dsR24" required=""></label>
</div>
<div id="field"><label for="DOB2"><b>Date of birth <span class="ds2">*</span> </b><br>
<input type="text" name="DOB2" id="DOB2" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy" required=""></label>
</div>
<div id="fieldset"><label for="Age"> <b>Age <span class="ds2">*</span> </b><br>
<input type="text" name="Age" id="Age" maxlength="3" class="dsR3" required=""></label>
</div>
<div id="fieldset"><label for="Weight"> <b>Weight <span class="ds2">*</span> </b><br>
<input type="text" name="Weight" id="Weight" maxlength="3" class="dsR3" required=""></label>
</div>
<div id="field"><label for="Reason"> <b>Reason for MRI and/or symptoms <span class="ds2">*</span> </b><br>
<textarea name="Reason" id="Reason" rows="5" cols="42" required=""></textarea></label>
</div>
<div id="field"><label for="Duration"> <b>How long have you had these symptoms? <span class="ds2">*</span> </b><br>
<input type="text" name="Duration" id="Duration" maxlength="24" class="dsR24"></label>
</div>
<div id="field"><b>Are symptoms a result of a motor vehicle accident? <span class="ds2">*</span> </b><br>
<input type="radio" name="MVA" value="MVAYes" id="MVAYes" x-sel="{{MVA}}" onclick="javascript:yesnoCheck1();" required=""><label for="MVAYes">Yes </label>
<input type="radio" name="MVA" value="MVANo" id="MVANo" x-sel="{{MVA}}" onclick="javascript:yesnoCheck1();"><label for="MVANo">No </label>
</div>
<div id="YesMVA" style="display:none">
<div id="field"><label for="AccidentDate"><b>Date of accident <span class="ds2">*</span> </b><br>
<input type="text" name="AccidentDate" id="AccidentDate" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
<div id="fieldset"><label for="AccidentState"> <b>State accident occurred <span class="ds2">*</span> </b><br>
<input type="text" name="AccidentState" id="AccidentState" maxlength="24" class="dsR24"></label>
</div>
</div>
</fieldset>
<fieldset>
<legend>Medical Information</legend>
<div id="field"><label for="SurgicalHx"> <b>Please list any surgical history by body part </b><br>
<textarea name="SurgicalHx" id="SurgicalHx" rows="5" cols="42"></textarea></label>
</div>
<div id="field"><b>Have you had a prior medical imaging study or exam (MRI, CT, X-Ray, etc.) on the body part we are looking at today? <span class="ds2">*</span> </b><br>
<input type="radio" name="PriorImaging" value="PriorImagingYes" id="PriorImagingYes" x-sel="{{PriorImaging}}" onclick="javascript:yesnoCheck2();" required=""><label for="PriorImagingYes">Yes </label>
<input type="radio" name="PriorImaging" value="PriorImagingNo" id="PriorImagingNo" x-sel="{{PriorImaging}}" onclick="javascript:yesnoCheck2();"><label for="PriorImagingNo">No </label>
</div>
<div id="YesPriorImaging" style="display:none">
<div id="field"><label for="PriorImagingList"> <b>Please list <span class="ds2">*</span> </b><br>
<textarea name="PriorImagingList" id="PriorImagingList" rows="5" cols="42"></textarea></label>
</div>
</div>
<div id="field"><b>Are there any medication allergies? <span class="ds2">*</span> </b><br>
<input type="radio" name="MedAllergies" value="MedAllergiesYes" id="MedAllergiesYes" x-sel="{{MedAllergies}}" onclick="javascript:yesnoCheck3();" required=""><label for="MedAllergiesYes">Yes </label>
<input type="radio" name="MedAllergies" value="MedAllergiesNo" id="MedAllergiesNo" x-sel="{{MedAllergies}}" onclick="javascript:yesnoCheck3();"><label for="MedAllergiesNo">No </label>
</div>
<div id="YesMedAllergies" style="display:none">
<div id="field"><label for="MedAllergiesList"> <b>Please list <span class="ds2">*</span> </b><br>
<textarea name="MedAllergiesList" id="MedAllergiesList" rows="5" cols="42"></textarea></label>
</div>
</div>
<div id="field"><b>Chance of pregnancy? <span class="ds2">*</span> </b><br>
<input type="radio" name="Pregnancy" value="PregnancyYes" id="PregnancyYes" x-sel="{{Pregnancy}}" required=""><label for="PregnancyYes">Yes </label>
<input type="radio" name="Pregnancy" value="PregnancyNo" id="PregnancyNo" x-sel="{{Pregnancy}}"><label for="PregnancyNo">No </label>
</div>
<div id="fieldset"><b>Currently breastfeeding? <span class="ds2">*</span> </b><br>
<input type="radio" name="Breastfeeding" value="BreastfeedingYes" id="BreastfeedingYes" x-sel="{{Breastfeeding}}" required=""><label for="BreastfeedingYes">Yes </label>
<input type="radio" name="Breastfeeding" value="BreastfeedingNo" id="BreastfeedingNo" x-sel="{{Breastfeeding}}"><label for="BreastfeedingNo">No </label>
</div>
<div id="field"><b>Any cancer history? <span class="ds2">*</span> </b><br>
<input type="radio" name="CancerHx" value="CancerHxYes" id="CancerHxYes" x-sel="{{CancerHx}}" onclick="javascript:yesnoCheck4();" required=""><label for="CancerHxYes">Yes </label>
<input type="radio" name="CancerHx" value="CancerHxNo" id="CancerHxNo" x-sel="{{CancerHx}}" onclick="javascript:yesnoCheck4();"><label for="CancerHxNo">No </label>
</div>
<div id="YesCancerHx" style="display:none">
<div id="fieldset"><label for="CancerHxList"> <b>Please list <span class="ds2">*</span> </b><br>
<textarea name="CancerHxList" id="CancerHxList" rows="5" cols="42"></textarea></label>
</div>
</div>
<div id="field"><b>Is there any chance of metal fragments (metallic slivers, shavings, foreign body, etc.) in your eyes from welding, grinding or from an injury? <span class="ds2">*</span> </b><br>
<input type="radio" name="Fragments" value="FragmentsYes" id="FragmentsYes" x-sel="{{Fragments}}" onclick="javascript:yesnoCheck5();" required=""><label for="FragmentsYes">Yes </label>
<input type="radio" name="Fragments" value="FragmentsNo" id="FragmentsNo" x-sel="{{Fragments}}" onclick="javascript:yesnoCheck5();"><label for="FragmentsNo">No </label>
</div>
<div id="YesFragments" style="display:none">
<div id="field"><b>Has all metal been removed by a physician? <span class="ds2">*</span> </b><br>
<input type="radio" name="FragmentsRemoved" value="FragmentsRemovedYes" id="FragmentsRemovedYes" x-sel="{{FragmentsRemoved}}"><label for="FragmentsRemovedYes">Yes </label>
<input type="radio" name="FragmentsRemoved" value="FragmentsRemovedNo" id="FragmentsRemovedNo" x-sel="{{FragmentsRemoved}}"><label for="FragmentsRemovedNo">No </label>
</div>
</div>
<div id="field">
<b>Are you or have you been in contact with someone experiencing any clinical symptoms consistent with Coronavirus including fever, respiratory illness, including persistent coughing, shortness of breath or other flu-like symptoms? <span class="ds2">*</span> </b><br>
<input type="radio" name="Coronavirus" value="CoronavirusYes" id="CoronavirusYes" x-sel="{{Coronavirus}}" required=""><label for="CoronavirusYes">Yes </label>
<input type="radio" name="Coronavirus" value="CoronavirusNo" id="CoronavirusNo" x-sel="{{Coronavirus}}"><label for="CoronavirusNo">No </label>
</div>
</fieldset>
<fieldset>
<legend>Safety Information</legend>
<div id="field"> Please answer each of the following safety questions – do any of the following apply? <span class="ds2">*</span>
</div>
<div style="clear:both;"></div>
<div id="columns">
<div id="field">
<input type="radio" name="Pacemaker" value="PacemakerYes" id="PacemakerYes" x-sel="{{Pacemaker}}" required="">Yes <input type="radio" name="Pacemaker" value="PacemakerNo" id="PacemakerNo" x-sel="{{Pacemaker}}"><label
for="PacemakerNo">No </label> Cardiac pacemaker or pacemaker
</div>
<div id="field">
<input type="radio" name="Cardioverter" value="CardioverterYes" id="CardioverterYes" x-sel="{{Cardioverter}}" required="">Yes <input type="radio" name="Cardioverter" value="CardioverterNo" id="CardioverterNo"
x-sel="{{Cardioverter}}"><label for="CardioverterNo">No </label> Wires implanted cardioverter
</div>
<div id="field">
<input type="radio" name="Neurostimulator" value="NeurostimulatorYes" id="NeurostimulatorYes" x-sel="{{Neurostimulator}}" required="">Yes <input type="radio" name="Neurostimulator" value="NeurostimulatorNo"
id="NeurostimulatorNo" x-sel="{{Neurostimulator}}"><label for="NeurostimulatorNo">No </label> Neurostimulator
</div>
<div id="field">
<input type="radio" name="BoneStimulator" value="BoneStimulatorYes" id="BoneStimulatorYes" x-sel="{{BoneStimulator}}" required="">Yes <input type="radio" name="BoneStimulator" value="BoneStimulatorNo" id="BoneStimulatorNo"
x-sel="{{BoneStimulator}}"><label for="BoneStimulatorNo">No </label> Bone growth stimulator
</div>
<div id="field">
<input type="radio" name="Infusion" value="InfusionYes" id="InfusionYes" x-sel="{{Infusion}}" required="">Yes <input type="radio" name="Infusion" value="InfusionNo" id="InfusionNo" x-sel="{{Infusion}}"><label
for="InfusionNo">No </label> Insulin or other infusion pump
</div>
<div id="field">
<input type="radio" name="Cochlear" value="CochlearYes" id="CochlearYes" x-sel="{{Cochlear}}" required="">Yes <input type="radio" name="Cochlear" value="CochlearNo" id="CochlearNo" x-sel="{{Cochlear}}"><label
for="CochlearNo">No </label> Cochlear ear implants
</div>
<div id="field">
<input type="radio" name="ArterialClips" value="ArterialClipsYes" id="ArterialClipsYes" x-sel="{{ArterialClips}}" required="">Yes <input type="radio" name="ArterialClips" value="ArterialClipsNo" id="ArterialClipsNo"
x-sel="{{ArterialClips}}"><label for="ArterialClipsNo">No </label> Arterial clips
</div>
<div id="field">
<input type="radio" name="Stent" value="StentYes" id="StentYes" x-sel="{{Stent}}" required="">Yes <input type="radio" name="Stent" value="StentNo" id="StentNo" x-sel="{{Stent}}"><label
for="StentNo">No </label> Stent, filter or coil in blood vessels
</div>
<div id="field">
<input type="radio" name="Prosthetic" value="ProstheticYes" id="ProstheticYes" x-sel="{{Prosthetic}}" required="">Yes <input type="radio" name="Prosthetic" value="ProstheticNo" id="ProstheticNo" x-sel="{{Prosthetic}}"><label
for="ProstheticNo">No </label> Artificial or prosthetic joint or limb
</div>
<div id="field">
<input type="radio" name="Piercing" value="PiercingYes" id="PiercingYes" x-sel="{{Piercing}}" required="">Yes <input type="radio" name="Piercing" value="PiercingNo" id="PiercingNo" x-sel="{{Piercing}}"><label
for="PiercingNo">No </label> Body piercing jewelry
</div>
<div id="field">
<input type="radio" name="Colonoscopy" value="ColonoscopyYes" id="ColonoscopyYes" x-sel="{{Colonoscopy}}" required="">Yes <input type="radio" name="Colonoscopy" value="ColonoscopyNo" id="ColonoscopyNo"
x-sel="{{Colonoscopy}}"><label for="ColonoscopyNo">No </label> Colonoscopy within the past year
</div>
<div id="field">
<input type="radio" name="Glucose" value="GlucoseYes" id="GlucoseYes" x-sel="{{Glucose}}" required="">Yes <input type="radio" name="Glucose" value="GlucoseNo" id="GlucoseNo" x-sel="{{Glucose}}"><label
for="GlucoseNo">No </label> Glucose monitor
</div>
</div>
<div id="columns">
<div id="field">
<input type="radio" name="Aneurysm" value="AneurysmYes" id="AneurysmYes" x-sel="{{Aneurysm}}" required="">Yes <input type="radio" name="Aneurysm" value="AneurysmNo" id="AneurysmNo" x-sel="{{Aneurysm}}"><label
for="AneurysmNo">No </label> Aneurysm clip(s)
</div>
<div id="field">
<input type="radio" name="ElectImplant" value="ElectImplantYes" id="ElectImplantYes" x-sel="{{ElectImplant}}" required="">Yes <input type="radio" name="ElectImplant" value="ElectImplantNo" id="ElectImplantNo"
x-sel="{{ElectImplant}}"><label for="ElectImplantNo">No </label> Electronic implant or device
</div>
<div id="field">
<input type="radio" name="Spinal" value="SpinalYes" id="SpinalYes" x-sel="{{Spinal}}" required="">Yes <input type="radio" name="Spinal" value="SpinalNo" id="SpinalNo" x-sel="{{Spinal}}"><label
for="SpinalNo">No </label> Spinal cord stimulator
</div>
<div id="field">
<input type="radio" name="Electrodes" value="ElectrodesYes" id="ElectrodesYes" x-sel="{{Electrodes}}" required="">Yes <input type="radio" name="Electrodes" value="ElectrodesNo" id="ElectrodesNo" x-sel="{{Electrodes}}"><label
for="ElectrodesNo">No </label> Internal electrodes or wires
</div>
<div id="field">
<input type="radio" name="EyeImplants" value="EyeImplantsYes" id="EyeImplantsYes" x-sel="{{EyeImplants}}" required="">Yes <input type="radio" name="EyeImplants" value="EyeImplantsNo" id="EyeImplantsNo"
x-sel="{{EyeImplants}}"><label for="EyeImplantsNo">No </label> Eye implants
</div>
<div id="field">
<input type="radio" name="Penile" value="PenileYes" id="PenileYes" x-sel="{{Penile}}" required="">Yes <input type="radio" name="Penile" value="PenileNo" id="PenileNo" x-sel="{{Penile}}"><label
for="PenileNo">No </label> Penile implant
</div>
<div id="field">
<input type="radio" name="Metal" value="MetalYes" id="MetalYes" x-sel="{{Metal}}" required="">Yes <input type="radio" name="Metal" value="MetalNo" id="MetalNo" x-sel="{{Metal}}"><label
for="MetalNo">No </label> Metal implants
</div>
<div id="field">
<input type="radio" name="Transdermal" value="TransdermalYes" id="TransdermalYes" x-sel="{{Transdermal}}" required="">Yes <input type="radio" name="Transdermal" value="TransdermalNo" id="TransdermalNo"
x-sel="{{Transdermal}}"><label for="TransdermalNo">No </label> Transdermal medication patch
</div>
<div id="field">
<input type="radio" name="Dentures" value="DenturesYes" id="DenturesYes" x-sel="{{Dentures}}" required="">Yes <input type="radio" name="Dentures" value="DenturesNo" id="DenturesNo" x-sel="{{Dentures}}"><label
for="DenturesNo">No </label> Removable dentures
</div>
<div id="field">
<input type="radio" name="BirthControl" value="BirthControlYes" id="BirthControlYes" x-sel="{{BirthControl}}" required="">Yes <input type="radio" name="BirthControl" value="BirthControlNo" id="BirthControlNo"
x-sel="{{BirthControl}}"><label for="BirthControlNo">No </label> Birth control implant
</div>
<div id="field">
<input type="radio" name="HearingAids" value="HearingAidsYes" id="HearingAidsYes" x-sel="{{HearingAids}}" required="">Yes <input type="radio" name="HearingAids" value="HearingAidsNo" id="HearingAidsNo"
x-sel="{{HearingAids}}"><label for="HearingAidsNo">No </label> Hearing aids
</div>
</div>
<div id="field"><label for="AddlInfo"> <b>Please list any additional information you feel is pertinent to today’s exam </b><br>
<textarea name="AddlInfo" id="AddlInfo" rows="5" cols="42"></textarea></label>
</div>
</fieldset>
<fieldset>
<div id="field">
<b>Patient Signature</b> – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
</div>
<div id="field">
<script type="text/javascript">
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be displayed.</canvas></div>
</div>
<div id="fieldset" style="padding-left: 20px;"><label for="DateSigned4"> <b>Date</b> <br>
<input type="text" name="DateSigned4" id="DateSigned4" class="dsR12 maskField" mask="99/99/9999" placeholder="mm/dd/yyyy"></label>
</div>
</fieldset>
<fieldset>
<div style="width: 98%; border: 2px solid #23446D; padding: 6px;" align="center"> Before entering the MRI scan room you must remove certain items from your person including:<br><br>
<b>Hearing aids, cell phone, hair pins, jewelry, watch, magnetic strip cards</b><br><br> Coliseum Imaging provides lockers and the MRI Technologist will direct you to one prior to your exam.
</div>
</fieldset>
<fieldset>
<div id="field">
<input type="submit" value="Submit Form" id="SubmitForm">
</div>
<div id="fieldset" style="padding-left: 20px; float: right;">
<a target="_blank" href="https://luxsci.com/perl/public/hipaa_seal.pl?verify=18146&auth=$1$uoivYwn8$MBL3Jrn.cTOhgjp5G72QC0&type=f&d=26269&c=The%20Highland%20Group%2C%20LLC"><img src="https://djrufvackyewl.cloudfront.net/s3/seal/03-Compliant-Forms.png" width="120" height="90" border="0" alt="LuxSci helps ensure HIPAA-compliance for email and web services." oncontextmenu="alert('Copying Prohibited by Law - Copyright held by Lux Scientiae, Incorporated'); return false;"></a>
</div>
</fieldset>
<script src="https://www.theformteam.com/InputMask.js">
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<script type="text/javascript">
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<script>
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<script>
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document.getElementById('YesWork').style.display = 'block';
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if (document.getElementById('PaymentVehicle').checked) {
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<script>
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<script>
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<script>
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} else document.getElementById('YesFragments').style.display = 'none';
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<input type="hidden" name="Today" id="Today" class="dsR12" value="2024-11-27">
<script>
(function() {
var date = new Date().toISOString().substring(0, 10);
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</form>Text Content
PATIENT INFORMATION FORM Patient Information Last Name * First Name * MI Address * Apt. No. City * State * Zip * Date of Birth * Under age 18? Social Security No. Phone * Email * Marital Status Single Married Sex Male Female Employer Emergency Contact * Contact Phone * Guardian Name * Guardian Date of Birth * Signature of Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature. Your web browser does not support HTML5 Canvas. Signature object cannot be displayed. Payment Information Which of the following apply to this visit? * I have healthcare insurance I will self-pay This is a work-related injury This is a motor vehicle-related injury Primary Insurance Carrier * Secondary Insurance Carrier Please Complete for all Workers Compensation Claims Date of Injury * Cause of Injury * Employer at Time of Injury * Claim No. (if known) Date of Injury * Claim No. (if known) Motor Vehicle Insurance * Patients please read and sign below Benefit Agreement I request that payment of authorized Benefits Coordination be made on my behalf to Coliseum Imaging for any services furnished me. I authorize any holder of medical information about me to release to the health care financing administration or my insurance company/agents any information needed to determine benefits payable for related services. A copy of this signature is as valid as the original. As a courtesy to you, we can file a claim to your insurance carrier/payor/attorney. Insurance Providers/Payors may deem this test medically unnecessary and there is no guarantee of benefits. By signing this form, I understand that I am financially responsible for any and all remaining balances. Authorized Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature. Your web browser does not support HTML5 Canvas. Signature object cannot be displayed. Date Please help us by following up with your insurance company for any unpaid claims -------------------------------------------------------------------------------- Notice of Intent to Protect Privacy (HIPAA) The department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. This rule requires providers to obtain patient consent to use their healthcare information for treatment, payment or other healthcare operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We also want you to know that we support your full access to your personal medical records. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Protected Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice. I hereby authorize the release of all or any portion of my medical records to any health care practitioner or facility designated by me. Authorized Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature. Your web browser does not support HTML5 Canvas. Signature object cannot be displayed. Date Name of person, if any, that you give permission to have access to your medical/billing records. Name Relationship -------------------------------------------------------------------------------- Patient Feedback Consent Coliseum Imaging Center is committed to providing the best possible patient experience and values your feedback. By signing below you hereby authorize Coliseum Imaging Center to send you a one-time text message to rate your experience and provide an opportunity to share feedback. Authorized Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature. Your web browser does not support HTML5 Canvas. Signature object cannot be displayed. Date MRI SCREENING FORM Patient Information Last name * First name * Date of birth * Age * Weight * Reason for MRI and/or symptoms * How long have you had these symptoms? * Are symptoms a result of a motor vehicle accident? * Yes No Date of accident * State accident occurred * Medical Information Please list any surgical history by body part Have you had a prior medical imaging study or exam (MRI, CT, X-Ray, etc.) on the body part we are looking at today? * Yes No Please list * Are there any medication allergies? * Yes No Please list * Chance of pregnancy? * Yes No Currently breastfeeding? * Yes No Any cancer history? * Yes No Please list * Is there any chance of metal fragments (metallic slivers, shavings, foreign body, etc.) in your eyes from welding, grinding or from an injury? * Yes No Has all metal been removed by a physician? * Yes No Are you or have you been in contact with someone experiencing any clinical symptoms consistent with Coronavirus including fever, respiratory illness, including persistent coughing, shortness of breath or other flu-like symptoms? * Yes No Safety Information Please answer each of the following safety questions – do any of the following apply? * Yes No Cardiac pacemaker or pacemaker Yes No Wires implanted cardioverter Yes No Neurostimulator Yes No Bone growth stimulator Yes No Insulin or other infusion pump Yes No Cochlear ear implants Yes No Arterial clips Yes No Stent, filter or coil in blood vessels Yes No Artificial or prosthetic joint or limb Yes No Body piercing jewelry Yes No Colonoscopy within the past year Yes No Glucose monitor Yes No Aneurysm clip(s) Yes No Electronic implant or device Yes No Spinal cord stimulator Yes No Internal electrodes or wires Yes No Eye implants Yes No Penile implant Yes No Metal implants Yes No Transdermal medication patch Yes No Removable dentures Yes No Birth control implant Yes No Hearing aids Please list any additional information you feel is pertinent to today’s exam Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature. Your web browser does not support HTML5 Canvas. Signature object cannot be displayed. Date Before entering the MRI scan room you must remove certain items from your person including: Hearing aids, cell phone, hair pins, jewelry, watch, magnetic strip cards Coliseum Imaging provides lockers and the MRI Technologist will direct you to one prior to your exam.