"Thank You front desk and staff for accommodation and caring for our patients."

~Shawanna, Dr. Mazarei, Dr. Tiu, and Tawana

Forms

Our patient forms are available below for your convenience. Please download the applicable forms in advance and bring the completed information with you to your appointment. Bringing the completed forms to your appointment will reduce your check in time.

Other items to bring to your appointment include: the order from your doctor, your insurance card, insurance authorization if required, and your photo ID.

New Patients

• Patient Registration
• Patient History Forms (Please note, not all procedures require a patient history form.)
  • Gynecological History Form (Pelvic Ultrasound, Endovaginal, Sonohysterogram/ Hystersonogram)
  • Obstetrical History Form (Obstetrical Ultrasound, Amniocentesis, Biophysical Profile, Nuchal Translucency Ultrasound)
  • Mammography History Form (Screening Mammogram, Diagnostic/Comprehensive Mammogram, Breast Cyst Aspiration, Breast Biopsy, and Breast Sonogram)
  • Bone Densitometry History Form
  • Patient Parking Permit (Please print and place on the dashboard of your vehicle when you arrive.)

Returning Patients

• Patient Registration (Complete if it has been over 6 months since your last visit or if any information has changed since your last visit)
• Patient History Forms (Please note, not all procedures require a patient history form.)
  • Gynecological History Form (Pelvic Ultrasound, Endovaginal, Sonohysterogram/ Hystersonograpm)
  • Obstetrical History Form (Obstetrical Ultrasound, Amniocentesis, Biophysical Profile, Nuchal Translucency Ultrasound)
  • Mammography History Form (Screening Mammogram, Diagnostic/Comprehensive Mammogram, Breast Cyst Aspiration, Breast Biopsy, and Breast Sonogram)
  • Bone Densitometry History Form
  • Patient Parking Permit (Please print and place on the dashboard of your vehicle when you arrive.)

Record Release

• Request to Release Health Information to Ultrasound Associates (Incoming Film/Images/CDs)
• Authorization to Release Health Information to another facility (Outgoing Film/Images/CDs)
• Record Release Payment Form