Radiology: Patient Forms
Forms for patients of the Radiology department at Campbell County Memorial
Hospital in Gillette, Wyoming. Forms are available in PDF.
CT Patient History Form:
DEXA History Form:
Image Release for Prior Imaging Form:
Note: Use this form to have previous mammography records or x-rays/imaging
records sent to CCMH Radiology.
Medical Record Release Form:
Release of Information Form
Use this form to request copies of studies performed by CCMH Radiology.
Submitted to Medical Records. Patient signature and a copy of their photo ID is required. (Must be over
age 18 or legal guardian)
Mammography History Form:
Medication and Allergy History Form:
Note: Please enter your current medications and if you have any allergic
/ adverse reactions to medications.
MRI History Form:
Note: Please make sure you sign on the back of this form.
Pregnancy History Form: