Request Phoenix

COVID-19 NOTIFICATION: If this is for a COVID patient, please let us know that in the comments box of this form.

Need this order STAT? Please call us at 602.971.9729 after you submit your order.
If exam is needed same day, please call in orders after normal office hours. Our office hours are Monday thru Friday, 8am to 4pm.
Questions? Call our Northern AZ office at 602.971.9729.
Fill out the online form below and click “Submit”. Your information is secure and HIPAA compliant.
To save a copy of your requested information, click the “Generate PDF” button at the bottom of the form BEFORE you click the submit button.

Online Orders:

* Facility Name / Room # Date of Service

SLF? ALF? IL / APT / Mobile Home?

* Patient Full Name * Date of Birth * Sex

* Physical Address

* Patient Phone Number Patient Social Security #

Full Name Contact Phone #

Hospice Carrier Hospice Covered

Primary Insurance Program Primary Insurance #

Secondary Insurance Program Secondary Insurance #

* Portable Exam Requested * How Many Views * ICD-10 Code

Portable Exam Requested #2 How Many Views ICD-10 Code Portable Exam Requested #3 How Many Views ICD-10Code

* Completed By * Ordering Physician (electronically authorized and signed by)

* Fax Results TO Phone Results TO

Comments (75 chars left) Attach File

STAT Same Day Service Routine (noon tomorrow)

* Portable x-ray(s) are required because the patient is unable to travel to a physician's office or other outpatient radiology facility due to the following clinical condition:

Optional – Save and Print Form Information Above:

CHROME BROWSER REQUIRED for this functionality. Follow these steps BEFORE you click the “SUBMIT” button above. You will not be able to save your information after your order has been submitted to us.

After you click the “Generate PDF” button, your information above will be processed into a PDF document.
When you see the “Print PDF” button appear below, your document is finished.
Click “Print PDF” to open or download your document.
When finished, click the “SUBMIT” button above to send your information to us. If you do not submit the form we will not receive your order.

Please note that downloaded PDF will reflect what you have entered above.

COVID-19 NOTIFICATION: If this is for a COVID patient, please let us know that in the comments box of this form.

Online Orders:

Patient Information

Guarantor / Guardian / Responsible Party Information

Patient Insurance Information

Clinical Information

Optional – Save and Print Form Information Above: