(805) 988-0616
Online Forms

In order to make your visit more convenient, we have made available forms for you to download and complete prior to arriving for your exam.

Please click on the link below to open and download the form. The forms are Adobe (.PDF) format and can be opened in Adobe Reader. If you do not have Adobe on your computer you can obtain a free Adobe download from their website.

Physician Referral Form
(Download Form)

Physician office may print and complete. Please fax to us at (805) 604-1722.

Physician Referral Form for PET/CT
(Download Form)

Physician office may print and complete. Please fax to us at (805) 988-0997.

Patient Registration Form
(Download Form)

Please print this form and fill it out. When finished, you can mail or fax (805) 604-1722 the completed from to Grossman Imaging Centers. If you prefer, you may bring the completed form with you on the day of the examination.

Patient MRI Safety Screening Form
(Download Form)

Please Print this form, complete and fax to us at (805) 604-1722. Bring completed form with you the day of the appointment.

Insurance Liability Form
(Download Form)

Please print out form, complete and fax to us at (805) 604-1722. Bring completed form with you to your appointment.


Patient Intake Form
HIPAA Authorization Form
GIC Confidentiality Agreement
Authorization to Release Information
GIC Notice of Privacy Practices (English)