Radiology Appointment Request

You may schedule your appointment online using this form for mammograms, ultrasounds, CT scans and all other radiology procedures. If you have any questions, or if you are having trouble with this form or would like to schedule your appointment via the phone please call (480) 882-4703. Thank you.

All fields in red are required.

First Name :
Last Name :
Address :
City :
State :	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Wake Island Washington West Virginia Wisconsin Wyoming
Zip :
Email :
Phone No :
Did a physician refer you here?  Yes No
Primary Care Physician :
Employer :
Is your health insurance through your employer ?   Yes No
Insurance Carrier :
Insurance ID # :
Date of Birth : (e.g. 03/17/1976)
Gender :	Male Female
Procedure Required :
Diagnosis :
Reason for exam :
Campus :	Osborn Shea Thompson Peak
Appointment Date Preference: (mo/day/year, i.e. 03/17/76)
No Preference :
Preference 1 :	A.M P.M
Preference 2 :	A.M P.M
Preference 3 :	A.M P.M