FRONT OFFICE CENTER

Here, you'll find specific forms and questionnaires related to your appointment and your study. If you have any questions, please contact our Front Office department at (203) 797-1770.

Click here to request ordering pads and appointment cards. We also provide prescription forms in Spanish and Portuguese. Or, call Maria Micelli at (203) 797-1770 ext. 3036.

Please note: If your child is under 18 years of age and able to drive to and from his/her appointment without a parent or guardian, he/she must bring a note signed by his/her parent or guardian giving HVRA permission to perform the examination.

Prescriptions & Forms:

Note: Access to the following prescriptions and forms require a doctor's user name and password. If you are a referring physician and do not have a user name and password, please call our main office at (203) 797-1770.

Diagnostic Ordering Form - required for all exams except MRI
Certificate of Medical Necessity
/ Bone Density Measurements - to be completed by the patient's referring doctor for bone density studies
MRI Prescription & Questionnaire - patients are required to this form prior to an MRI; referring doctors may use this form to order an MRI.

Patient Forms:

Patient Information Form - required for all exams
No Fault / Personal Injury Information
Worker's Compensation Information

Additional MRI Questionnaires for Patients:

Breast MRI Questionnaire
MRI Body (English)
MRI Body (Spanish)
MRI Joint and Muscle (English)
MRI Joint and Muscle (Spanish)
Prophylactic Treatment Regimen for Gadolinium
Brain MRI Questionnaire
Cervical MRI Questionnaire
Low Back MRI Questionnaire

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