Please complete the following registration form. You will be given a chance to review this information, and make additions or corrections, at the time of your appointment.

Part 1: Patient Information
Patient's First Name:  
     
Middle Initial:    
     
Last Name:    
     
Suffix:    
     
Date of Birth:          
     
Gender:   Male     Female
     
Marital Status:   Married     Single     Divorced     Widowed
     
Social Security #:     - -
     
Home Address:    
     
City:    
     
State:    
     
Zip:    
     
Home Phone #:     - -
     
Work Phone #:     - -   Ext.
     
Cell Phone #:     - -
     
Email Address:    
     
Emergency Contact:    
     
Relationship to Emergency Contact:    
     
Emergency Contact Phone:     - -
     
Employment Status:   Full-time     Part-time     Student
     
Employer:    
     
Employer Address:    
     
City:    
     
State:    
     
Zip:    
     
Employer Phone #:     - -
     
Is this visit related to an injury?   Work     Auto     Other   
     
Date of Injury:          
     
Where and how did the injury occur?    




Part 2: Insurance Information
Primary Insurance Carrier:    
     
Policy #:    
     
Group #:    
     
Group Name:

    

     
Secondary Insurance Carrier:    
     
Policy #:    
     
Group #:    
     
Group Name:    


Please bring your insurance card with you on the day of your appointment.




Part 3: Policy Holder Information

Please fill out this section ONLY if the policy holder is someone other than the patient.

How is the patient related to the policy holder?:   Spouse     Child     Other   
     
Policy Holder's First Name:    
     
Middle Initial:    
     
Last Name:    
     
Suffix:    
     
Date of Birth:          
     
Gender:   Male     Female
     
Social Security #:     - -
     
Policy Holder's Home Address:    
     
City:    
     
State:    
     
Zip:    
     
Home Phone #:     - -
     
Work Phone #:     - -   Ext.
     
Employment Status:   Full-time     Part-time
     
Policy Holder's Employer:    
     
Employer Address:    
     
City:    
     
State:    
     
Zip:    
     
Employer Phone #:     - -




Part 4: Guarantor's Information (Responsible Party)

Please fill out this section ONLY if the patient is a minor and ONLY if the patient will be accompanied by a Responsible Party who is not the Policy Holder. Patients under the age of eighteen must be accompanied by a parent or legal guardian.
How is the patient related to the Guarantor?:   Child     Other   
     
Guarantor's First Name:    
     
Middle Initial:    
     
Last Name:    
     
Suffix:    
     
Social Security #:     - -
     
Guarantor's Home Address:    
     
City:    
     
State:    
     
Zip:    
     
Home Phone #:     - -
     
Work Phone #:     - -   Ext.
     
Cell Phone #:     - -
     
Email Address:    
     
Guarantor's Employer:    
     
Employer Address:    
     
City:    
     
State:    
     
Zip:    
     
Employer Phone #:     - -




Part 5: Exam-Related Information

MRI exams, CT exams and mammograms require additional patient information. Please indicate if you are scheduled for one or more of these exams, and after clicking SUBMIT you will be taken to the appropriate form(s):

MRI     CT     Mammogram




 

Metro Imaging is the exclusive provider of OnSite Results. You will receive the preliminary findings of your imaging exams before you leave the building. The choice is yours. The results are now.

Metro Imaging offers online registration, enabling you to fill out personal and medical information before your visit. It saves you time, making the day of your appointment that much easier.

After your exam, we invite you to complete a short survey about your experience at Metro Imaging. We are always looking for ways to serve you better, and value your feedback.

Are you concerned about how much your MRI, CT scan, ultrasound or other imaging exam will cost? You may pay significantly more for your exam at a hospital than you will pay at Metro Imaging.