Prepare for Your Visit
Patient Info
Helping with Your Care
Thank you for choosing SimonMed Imaging for your medical imaging. For your added convenience please use the links below.
Click here to complete your forms online prior to your appointment.
For any additional questions, please call or text us at
1-866-614-8555 or email us at [email protected].
Prep Instructions
Preparation Instructions to review before your exam.
Patient Information Form - English
Consent to Treat.
Patient Information Form - Spanish
Consent to Treat.
Medical Records Policy
Process of Requesting Medical Records.
Medical Records Request Form - English
Authorization to Release PHI.
Medical Records Request Form - Spanish
Authorization to Release PHI
Cost Estimates Explained
SimonMed provides estimates based on insurance provided
Personal Injury Patient Forms
Arizona Forms
Florida Forms
All Other State Forms
Patient Lien Form English - AZ
Lien Form for PI Patients in Arizona
Patient Lien Form English - FL
Lien Form for PI Patients in Florida
Patient Lien Form - English
Authorization to Release PHI to Attorney
Patient Lien Form Spanish - AZ
Lien Form for PI Patients in Arizona
Patient Lien Form Spanish - FL
Lien Form for PI Patients in Florida
Patient Lien Form - Spanish
Authorization to Release PHI to Attorney
Why Choose Us
SimonMed Imaging and its affiliates have been serving the community for over 30 years. Our mission is to provide best-in class affordable care through the use of advanced technology. We have patient-focused staff and highly trained medical professionals.
SimonMed has over 160 convenient locations across 11 states and provides late night and weekend appointments to accommodate patients.
