Patient Forms

Thank you for choosing The Hill Medical Corporation for your diagnostic procedure(s). Whether you’re a new or existing patient, please review the following documents before your next appointment. Depending on your examination or procedure, you can save time by filling out the patient forms before your next visit with us.

Patient Form

If you’re a NEW patient or have UPDATED information, please print and bring the completed form to your upcoming appointment. For returning patients, a pre-printed form will be ready for your review upon your next appointment.


Meaningful Use Questionnaire

New regulations require our centers to document patient’s health history and communication preferences in an electronic format. All NEW patients or patients with UPDATED information are required to fill out the form.


MRI Contrast Consent Form

(Fair Oaks, Cordova and Glendora locations only)
If your doctor has referred you to our imaging center for a Magnetic Resonance Imaging (MRI) examination requiring an injection of Gadolinium‐Based MRI contrast, please take a moment to read the Consent Form and medication guides. Please bring the signed consent form with you on the day of your appointment. If you have additional questions regarding Gadolinium‐Based MRI contrast, please visit our Patient Education page.

A Medication Guide will be given to you on the day of your MRI with contrast exam. We encourage you to review the information in advance by using the links below. There are a number of different gadolinium-based contrast agents available, each with its own safety profile. Hill Medical has considered retention characteristics when selecting the two gadolinium-based contrast agents used at its imaging centers. Additional factors to be considered include the part of the body being imaged, your medical condition(s) and history, and prior MRI with contrast exams.


Authorization Form

The authorization form is for use or disclosure of protected health information. Patients, please use this form when you wish to have your protected health information released to you or another party. You may bring this form to our office or fax it to our medical records dept at (626) 229-8988.


Personal Liens – Intake form & Waiver of Private Health Information

Hill Medical’s West Covina location, the Hill Imaging Center, is now accepting personal lien (PI) cases. PI cases are managed through a third party vendor and will require additional documentation. If you have any questions, regarding your case please contact Red Rock Diagnostics at (702) 362-6077. Patients may also fax in their PI forms at (702) 362-5132.


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