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  • HOME
  • ABOUT DRA
    • NEWS AND EVENTS
    • MEET OUR PHYSICIANS
    • LOCATIONS
    • OUR AFFILIATES
    • WOMEN’S IMAGING CENTER
    • VALLEY IMAGING PARTNERS
    • VEIN CENTER
    • ACCREDITATIONS
    • CONTACT US
  • OUR SERVICES
    • CT SCAN
    • WOMEN’S IMAGING
    • DEXA BONE DENSITOMETRY
    • MRI
    • ULTRASOUND
    • XRAY
    • INTERVENTIONAL RADIOLOGY
  • FOR PATIENTS
    • EXAM PREPARATIONS
    • LOCATIONS
    • DOWNLOAD FORMS
    • REQUEST YOUR IMAGES
    • REQUEST AN APPOINTMENT
    • PATIENT PORTAL
    • INTERPRETATION SERVICES
    • PAY YOUR BILL
    • CONTACT US
  • FOR PHYSICIANS
    • VIEW IMAGES
    • EXAMS BY LOCATION
    • DOWNLOAD REQUISITIONS
    • PRIOR AUTHORIZATION DEPARTMENT
    • CONTACT US
  • HOME
  • ABOUT DRA
    • NEWS AND EVENTS
    • MEET OUR PHYSICIANS
    • LOCATIONS
    • OUR AFFILIATES
    • WOMEN’S IMAGING CENTER
    • VALLEY IMAGING PARTNERS
    • VEIN CENTER
    • ACCREDITATIONS
    • CONTACT US
  • OUR SERVICES
    • CT SCAN
    • WOMEN’S IMAGING
    • DEXA BONE DENSITOMETRY
    • MRI
    • ULTRASOUND
    • XRAY
    • INTERVENTIONAL RADIOLOGY
  • FOR PATIENTS
    • EXAM PREPARATIONS
    • LOCATIONS
    • DOWNLOAD FORMS
    • REQUEST YOUR IMAGES
    • REQUEST AN APPOINTMENT
    • PATIENT PORTAL
    • INTERPRETATION SERVICES
    • PAY YOUR BILL
    • CONTACT US
  • FOR PHYSICIANS
    • VIEW IMAGES
    • EXAMS BY LOCATION
    • DOWNLOAD REQUISITIONS
    • PRIOR AUTHORIZATION DEPARTMENT
    • CONTACT US
dra logo
dra logo
  • HOME
  • ABOUT DRA
    • NEWS AND EVENTS
    • MEET OUR PHYSICIANS
    • LOCATIONS
    • OUR AFFILIATES
    • WOMEN’S IMAGING CENTER
    • VALLEY IMAGING PARTNERS
    • VEIN CENTER
    • ACCREDITATIONS
    • CONTACT US
  • OUR SERVICES
    • CT SCAN
    • WOMEN’S IMAGING
    • DEXA BONE DENSITOMETRY
    • MRI
    • ULTRASOUND
    • XRAY
    • INTERVENTIONAL RADIOLOGY
  • FOR PATIENTS
    • EXAM PREPARATIONS
    • LOCATIONS
    • DOWNLOAD FORMS
    • REQUEST YOUR IMAGES
    • REQUEST AN APPOINTMENT
    • PATIENT PORTAL
    • INTERPRETATION SERVICES
    • PAY YOUR BILL
    • CONTACT US
  • FOR PHYSICIANS
    • VIEW IMAGES
    • EXAMS BY LOCATION
    • DOWNLOAD REQUISITIONS
    • PRIOR AUTHORIZATION DEPARTMENT
    • CONTACT US

DOWNLOAD FORMS

Home DOWNLOAD FORMS

Forms to Fill out before your visit

For Mammography Patients

Mammography Questionnaire
Spanish Mammography Questionnaire
Specialist Mammogram Page 1
Specialist Mammography Page 2

For MRI Patients

MRI Consent Form
MRI Safety Questionnaire

For CT Scan Patients

IV Contrast Questionnaire
IV Contrast Consent Form

For New Vein Center Patients

Vein Center Patient Health History Form – Venous Insufficiency For New Patients

For Uterine Fibriod New Patients

DRA Patient Health History Form – Uterine Fibroid Embolization For New Patients

Informational Forms

BRCA Screening FAQs
Genetic Counseling

For MDs Only

Patient Referral Form

Southbury Referral

Southbury Referral Pad
Waterbury Referral Pad

American College of Radiology
Are You Dense
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Waterbury Location
Medical Arts Building
134 Grandview Avenue Suite 101
Waterbury, CT 06708
203-756-8911
Fax: 203-574-3298

Middlebury Location
Turnpike Office Park Lower Level
1579 Straits Turnpike
Middlebury, CT 06762
203-758-2588
Fax: 203-758-2599

Southbury Location
Women’s Imaging Center
32 Poverty Road, Suite B
Southbury, CT 06488
Tel: 203-262-6797
Fax: 203-262-6006

Southbury Location
690 Main Street South
Suite 7LL
Southbury, CT 06488
Tel: 203-755-OPEN (6736) 
Fax  203-262-6006
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