Request Exam Name* First Last Email* Phone*Gender* Male Female Birthdate* Month Day Year Zip Code*How did you hear about us?*Google SearchBing SearchDoctor ReferralReferred from a friendAdvertisementFacebookTwitterYelpOther Do you have an order to upload?* Yes No Please upload your order here to avoid delays Drop files here or Select files Max. file size: 50 MB. What procedures do you need?*MRI without contrastMRI with contrastMRI with and without contrastPET/CT ScanCT Scan without contrastCT Scan with contrastCT Scan with and without contrastArthrogramUltrasoundX-RayMammogramBone DensityEchocardiogramMyelogramNuclear MedicineInterventional Pain ManagementOther ExamSelect from the drop list the diagnostic imaging service in which you are interested.Indicate body part for the procedure.Indicate body part for the procedure.How do you intend to pay?*My employer offers Affordable MRI as a benefitUninsured/High Deductible Self-PayHealth sharing cooperativeOther Health sharing cooperative* Drop files here or Select files Max. file size: 50 MB. Health sharing cooperative Preferred Day of the WeekMondayTuesdayWednesdayThursdayFridayPreferred Time 8am – 10am 10am – 12pm 1pm – 3pm 3pm – 5pm Other Looking for affordable CT, X-ray, or other imaging? Start here
