Imaging Forms

As ChristianaCare works to protect our community, our patients and our caregivers from coronavirus COVID-19, some ChristianaCare Imaging Service sites are temporarily closed. Centralized Scheduling will remain operational for new scheduling requests and scheduling questions at 302-838-3088 or toll-free 877-838-3088.

You may be asked to print and fill out one or more of the following forms before your visit. Please call 302-838-3088 or toll-free 877-838-3088 if you have any questions.

General Imaging Forms

• Authorization to Release Health Information Form
  Complete to release health information from ChristianaCare.
• Authorization to Request Health Information Form
  Complete when requesting health information from other healthcare provider(s).
• Conditions for Treatment
• Condiciones de Tratamiento (español)
• 治疗条件和财务责任 (中文普通话社区)

CT/CTA Scan Forms

• CT/CTA Scan History
• Historial de Pruebas de Tomografía Computarizada (español)

Mammography/Breast Imaging Forms

• Breast Imaging Patient History
• Imágenes Previas del Seno del Paciente (español)

MRI Forms

• MRI Questionnaire
• Questionario de MRI (español)

To request an appointment, call 302-838-3088 or toll-free 877-838-3088.