**** ATTENTION PATIENT PLEASE BRING THIS FORM TO YOUR APPOINTMENT***** - radiology uic 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your personal information in the designated fields, including your name, date of birth, and contact numbers. This ensures that the clinic can reach you if necessary.
  3. Next, specify your appointment date and time. This helps the clinic prepare for your visit.
  4. Indicate your insurance details and select the procedure requested from the provided options. If contrast is needed, make sure to check 'Yes' or 'No' accordingly.
  5. Answer health-related questions regarding pregnancy, claustrophobia, and any allergies. This information is crucial for your safety during procedures.
  6. Complete any additional sections regarding medical history and physician details before saving or printing the form.

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