This space is reserved for requesting your appointment. Once you have submitted your filled out form, one of our representatives will reach out to confirm your appointment.
Copy of medical order
Copy of Insurance card
Referral (if applicable)
Copy of photo ID
BUN & Creatinine Labs
Security Questions
Retainers:YesNo
Disability:YesNo
Defibrillator:YesNo
Neurostimulator:YesNo
Braces:YesNo
Bypass:YesNo
Implants:YesNo
Clip / Markers:YesNo
Biopsy:YesNo
Aneurysm Clip:YesNo
Intraocular lense:YesNo
Foreign Objects:YesNo
Gunshot Wound:YesNo
DMG (Diabetics):YesNo
Pregnancy (Ladies):YesNo
Hair Extentions:YesNo
Expanders:YesNo Year of Surgery:
Mesh / Stent:YesNo Year of Surgery:
Pacemaker:YesNo Year of Surgery:
Prosthesis:YesNo Year of Surgery:
Welder (any injuries):YesNo Year of Surgery:
Metal Plate:YesNo
Screws:YesNo Year of Surgery & Material:
Claustrophobia:Yes – MildYes – ModerateYes – SevereNo
