{"id":355,"date":"2024-03-27T20:49:17","date_gmt":"2024-03-27T20:49:17","guid":{"rendered":"http:\/\/52.43.26.27\/?page_id=355"},"modified":"2026-03-16T13:10:47","modified_gmt":"2026-03-16T20:10:47","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/www.salemradiology.com\/?page_id=355","title":{"rendered":"Patient Forms"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"355\" class=\"elementor elementor-355\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6ffcda7 e-flex e-con-boxed e-con e-parent\" data-id=\"6ffcda7\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-e9ef02d e-con-full e-flex e-con e-child\" data-id=\"e9ef02d\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-49a00b2 elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"49a00b2\" data-element_type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.salemradiology.com\/wp-content\/uploads\/2026\/03\/Notice-of-Privacy-Practices_New-Patients.pdf\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zM332.1 128H256V51.9l76.1 76.1zM48 464V48h160v104c0 13.3 10.7 24 24 24h104v288H48zm250.2-143.7c-12.2-12-47-8.7-64.4-6.5-17.2-10.5-28.7-25-36.8-46.3 3.9-16.1 10.1-40.6 5.4-56-4.2-26.2-37.8-23.6-42.6-5.9-4.4 16.1-.4 38.5 7 67.1-10 23.9-24.9 56-35.4 74.4-20 10.3-47 26.2-51 46.2-3.3 15.8 26 55.2 76.1-31.2 22.4-7.4 46.8-16.5 68.4-20.1 18.9 10.2 41 17 55.8 17 25.5 0 28-28.2 17.5-38.7zm-198.1 77.8c5.1-13.7 24.5-29.5 30.4-35-19 30.3-30.4 35.7-30.4 35zm81.6-190.6c7.4 0 6.7 32.1 1.8 40.8-4.4-13.9-4.3-40.8-1.8-40.8zm-24.4 136.6c9.7-16.9 18-37 24.7-54.7 8.3 15.1 18.9 27.2 30.1 35.5-20.8 4.3-38.9 13.1-54.8 19.2zm131.6-5s-5 6-37.3-7.8c35.1-2.6 40.9 5.4 37.3 7.8z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Notice of Privacy Practices<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.salemradiology.com\/wp-content\/uploads\/2026\/03\/Release-of-Records-Request.pdf\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zM332.1 128H256V51.9l76.1 76.1zM48 464V48h160v104c0 13.3 10.7 24 24 24h104v288H48zm250.2-143.7c-12.2-12-47-8.7-64.4-6.5-17.2-10.5-28.7-25-36.8-46.3 3.9-16.1 10.1-40.6 5.4-56-4.2-26.2-37.8-23.6-42.6-5.9-4.4 16.1-.4 38.5 7 67.1-10 23.9-24.9 56-35.4 74.4-20 10.3-47 26.2-51 46.2-3.3 15.8 26 55.2 76.1-31.2 22.4-7.4 46.8-16.5 68.4-20.1 18.9 10.2 41 17 55.8 17 25.5 0 28-28.2 17.5-38.7zm-198.1 77.8c5.1-13.7 24.5-29.5 30.4-35-19 30.3-30.4 35.7-30.4 35zm81.6-190.6c7.4 0 6.7 32.1 1.8 40.8-4.4-13.9-4.3-40.8-1.8-40.8zm-24.4 136.6c9.7-16.9 18-37 24.7-54.7 8.3 15.1 18.9 27.2 30.1 35.5-20.8 4.3-38.9 13.1-54.8 19.2zm131.6-5s-5 6-37.3-7.8c35.1-2.6 40.9 5.4 37.3 7.8z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Release of Records Request<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"http:\/\/expertpracticemarketing.com\/myprac1\/public\/feedback-form.php?profileid=249687&#038;type=desktop&#038;status=1%27%20style=\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zM332.1 128H256V51.9l76.1 76.1zM48 464V48h160v104c0 13.3 10.7 24 24 24h104v288H48zm250.2-143.7c-12.2-12-47-8.7-64.4-6.5-17.2-10.5-28.7-25-36.8-46.3 3.9-16.1 10.1-40.6 5.4-56-4.2-26.2-37.8-23.6-42.6-5.9-4.4 16.1-.4 38.5 7 67.1-10 23.9-24.9 56-35.4 74.4-20 10.3-47 26.2-51 46.2-3.3 15.8 26 55.2 76.1-31.2 22.4-7.4 46.8-16.5 68.4-20.1 18.9 10.2 41 17 55.8 17 25.5 0 28-28.2 17.5-38.7zm-198.1 77.8c5.1-13.7 24.5-29.5 30.4-35-19 30.3-30.4 35.7-30.4 35zm81.6-190.6c7.4 0 6.7 32.1 1.8 40.8-4.4-13.9-4.3-40.8-1.8-40.8zm-24.4 136.6c9.7-16.9 18-37 24.7-54.7 8.3 15.1 18.9 27.2 30.1 35.5-20.8 4.3-38.9 13.1-54.8 19.2zm131.6-5s-5 6-37.3-7.8c35.1-2.6 40.9 5.4 37.3 7.8z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Enter a Patient Testimonial<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.salemradiology.com\/wp-content\/uploads\/2026\/03\/WEB-SITE-TERMS-AND-CONDITIONS-OF-USE.doc\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zM332.1 128H256V51.9l76.1 76.1zM48 464V48h160v104c0 13.3 10.7 24 24 24h104v288H48zm250.2-143.7c-12.2-12-47-8.7-64.4-6.5-17.2-10.5-28.7-25-36.8-46.3 3.9-16.1 10.1-40.6 5.4-56-4.2-26.2-37.8-23.6-42.6-5.9-4.4 16.1-.4 38.5 7 67.1-10 23.9-24.9 56-35.4 74.4-20 10.3-47 26.2-51 46.2-3.3 15.8 26 55.2 76.1-31.2 22.4-7.4 46.8-16.5 68.4-20.1 18.9 10.2 41 17 55.8 17 25.5 0 28-28.2 17.5-38.7zm-198.1 77.8c5.1-13.7 24.5-29.5 30.4-35-19 30.3-30.4 35.7-30.4 35zm81.6-190.6c7.4 0 6.7 32.1 1.8 40.8-4.4-13.9-4.3-40.8-1.8-40.8zm-24.4 136.6c9.7-16.9 18-37 24.7-54.7 8.3 15.1 18.9 27.2 30.1 35.5-20.8 4.3-38.9 13.1-54.8 19.2zm131.6-5s-5 6-37.3-7.8c35.1-2.6 40.9 5.4 37.3 7.8z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Web Site Terms and Conditions of Use<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.salemradiology.com\/wp-content\/uploads\/2025\/08\/Financial-Assistance.pdf\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zM332.1 128H256V51.9l76.1 76.1zM48 464V48h160v104c0 13.3 10.7 24 24 24h104v288H48zm250.2-143.7c-12.2-12-47-8.7-64.4-6.5-17.2-10.5-28.7-25-36.8-46.3 3.9-16.1 10.1-40.6 5.4-56-4.2-26.2-37.8-23.6-42.6-5.9-4.4 16.1-.4 38.5 7 67.1-10 23.9-24.9 56-35.4 74.4-20 10.3-47 26.2-51 46.2-3.3 15.8 26 55.2 76.1-31.2 22.4-7.4 46.8-16.5 68.4-20.1 18.9 10.2 41 17 55.8 17 25.5 0 28-28.2 17.5-38.7zm-198.1 77.8c5.1-13.7 24.5-29.5 30.4-35-19 30.3-30.4 35.7-30.4 35zm81.6-190.6c7.4 0 6.7 32.1 1.8 40.8-4.4-13.9-4.3-40.8-1.8-40.8zm-24.4 136.6c9.7-16.9 18-37 24.7-54.7 8.3 15.1 18.9 27.2 30.1 35.5-20.8 4.3-38.9 13.1-54.8 19.2zm131.6-5s-5 6-37.3-7.8c35.1-2.6 40.9 5.4 37.3 7.8z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Application for Financial Assistance<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.salemradiology.com\/wp-content\/uploads\/2025\/08\/Spanish-Application-for-Financial-Assistance.pdf\" target=\"_blank\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-far-file-pdf\" viewBox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M369.9 97.9L286 14C277 5 264.8-.1 252.1-.1H48C21.5 0 0 21.5 0 48v416c0 26.5 21.5 48 48 48h288c26.5 0 48-21.5 48-48V131.9c0-12.7-5.1-25-14.1-34zM332.1 128H256V51.9l76.1 76.1zM48 464V48h160v104c0 13.3 10.7 24 24 24h104v288H48zm250.2-143.7c-12.2-12-47-8.7-64.4-6.5-17.2-10.5-28.7-25-36.8-46.3 3.9-16.1 10.1-40.6 5.4-56-4.2-26.2-37.8-23.6-42.6-5.9-4.4 16.1-.4 38.5 7 67.1-10 23.9-24.9 56-35.4 74.4-20 10.3-47 26.2-51 46.2-3.3 15.8 26 55.2 76.1-31.2 22.4-7.4 46.8-16.5 68.4-20.1 18.9 10.2 41 17 55.8 17 25.5 0 28-28.2 17.5-38.7zm-198.1 77.8c5.1-13.7 24.5-29.5 30.4-35-19 30.3-30.4 35.7-30.4 35zm81.6-190.6c7.4 0 6.7 32.1 1.8 40.8-4.4-13.9-4.3-40.8-1.8-40.8zm-24.4 136.6c9.7-16.9 18-37 24.7-54.7 8.3 15.1 18.9 27.2 30.1 35.5-20.8 4.3-38.9 13.1-54.8 19.2zm131.6-5s-5 6-37.3-7.8c35.1-2.6 40.9 5.4 37.3 7.8z\"><\/path><\/svg>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Applicacio\u0301n Para Asistencia Financiera<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a578020 elementor-widget elementor-widget-text-editor\" data-id=\"a578020\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tAll forms on this website are created using the .pdf format. Adobe provides a free reader which is available on their website. If you are unable to open any of the files, be sure to <a id=\"MainContent_HyperLink6\" href=\"http:\/\/get.adobe.com\/reader\/\" target=\"_blank\" rel=\"noopener noreferrer\">download and install the Adobe Acrobat Reader<\/a>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-bac6d30 e-con-full e-flex e-con e-child\" data-id=\"bac6d30\" data-element_type=\"container\" data-settings=\"{&quot;sticky&quot;:&quot;top&quot;,&quot;sticky_offset&quot;:30,&quot;sticky_parent&quot;:&quot;yes&quot;,&quot;sticky_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;],&quot;sticky_effects_offset&quot;:0,&quot;sticky_anchor_link_offset&quot;:0}\">\n\t\t<div class=\"elementor-element elementor-element-a672634 e-flex e-con-boxed e-con e-child\" data-id=\"a672634\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e4830df elementor-widget elementor-widget-heading\" data-id=\"e4830df\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Contact Us Today!<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8de0139 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"8de0139\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6d1ff80 elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"6d1ff80\" data-element_type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"355\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"6d1ff80\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Patient Forms &#x2d; 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