Registration
You may print your registration forms and fill in the information requested prior to your MRI or Ultrasound appointment. Completing the forms below will ensure a smooth registration process once you arrive at the University of Miami Outpatient Diagnostic Imaging Center.
To view and print selected forms you must have Adobe Acrobat Reader software installed on your computer. This software allows you to open, view, and print Portable Document Format (files) from your computer. You can download a free copy of this software by clicking the link above.
MRI REGISTRATION FORMS
English
- UM Applebaum Diagnostic Imaging Center Pre-MRI Screening Form
- University of Miami School of Medicine Patient Consent for Medical Treatment
- UM Applebaum Diagnostic Imaging Center Disclosure and General Consent for Magnetic Resonance Imaging
- Assignment of Benefits
- Patient Questionnaire Abdomen/Pelvis Evaluation
- Patient Questionnaire Brain Evaluation
- Patient Questionnaire Form Breast Evaluation
- Patient Questionnaire Form Chest Evaluation
- Patient Questionnaire Form MRI Evaluation Miscellaneous
- Patient Questionnaire Form Right/Left Elbow Evaluation
- Patient Questionnaire Form Right/Left Hip Evaluation
- Patient Questionnaire Form Right/Left Knee Evaluation
- Patient Questionnaire Form Right/Left Shoulder Evaluation
- Patient Questionnaire Form Right/Left TMJ Joint
- Patient Questionnaire Form Right/Left Wrist Evaluation
- Patient Questionnaire Form Right/Left Sinus Evaluation
- Patient Questionnaire Form Right/Left Soft Neck Tissue Evaluation
- Patient Questionnaire Form Right/Left Spine Evaluation
Spanish
- UM Applebaum Diagnostic Imaging Center Cuestionario de Precaución Pre-MRI
- University of Miami School of Medicine Consentimiento para el Tratamiento Médico
- UM Applebaum Diagnostic Imaging Center Explicación del Procedimiento y Consentimiento Para Realizar el Estudio Mediante la Imaginología por Resonancia Magnética
- Asignación de Beneficios
Optional Forms – If you would like a companion to accompany you in the examination room please complete the forms below:
English
- Companion Pre-MRI Screening Form
- Advance Beneficiary Notice
- Notice of Exclusions from Medicare Benefits
Spanish
- Cuestionario de Precaución para Acompañantes del Paciente
- Notificacion Previa al Beneficiario de Medicare
- Notificacion de Exclusiones de los Beneficios de Medicare
ULTRASOUND REGISTRATION FORMS
English
- UM Applebaum Diagnostic Imaging Center Ultrasound Screening Form
- University of Miami School of Medicine Patient Consent for Medical Treatment
- Assignment of Benefits
Spanish
- UM Applebaum Diagnostic Imaging Center Cuestionario de Precaución para Estudios Ultrasonográficos
- University of Miami School of Medicine Consentimiento para el Tratamiento Médico
- Asignación de Beneficios
