For a printable copy of this form click here Registration & Consent Form Referring Doctor' * Referring Doctor's Location * Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Female Male N/B Any Chance of Pregnancy? * Yes No Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country CONTENT & RELEASE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I consent to allow New Standard Imaging to use and disclose my HEALTH INFORMATION in order to carry out treatment and healthcare operations. By endorsing this form, I am consenting to New Standard Imaging use and disclosure of my information as detailed above. However, I may give notice to restrict the use of such information and revoke my consent in writing. I understand that I have the right to review the NOTICE OF PRIVACY PRACTICES for a more complete description of such uses and disclosures prior to endorsing the consent. Type Name to Consent * Date Signed * MM DD YYYY Thank you!