SDI Radiology Appointment Request Form- Providers

Request an Appointment for Your Patient

Please fill in the form below to request an appointment. One of our staff will reach out to your patient within the next 72 hours to complete the scheduling process or provide any updates on the status of the request. ***For STAT appointment requests, please call the clinic.***
Please select a location*
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referring Provider Information
Your Name*

First NameLast Name
Your Office Phone Number
Please enter a valid phone number.
Please upload a copy of the order here:*

If the attachment is larger than 5 MB, please fax it to the office instead.
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Appointment Request Information
SDI Kearny Mesa- Exam Type
SDI Kearny Mesa- Exam Body Part
SDI Chula Vista- Exam Type
SDI Chula Vista- Exam Body Part
Diagnosis:
Patient's Preferred Appointment Day (Select all that apply)

MondayTuesdayWednesdayThursdayFriday
MRI CV Patient's Preferred Appointment Day (Select all that apply)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Patient's Preferred Appointment Time (Select all that apply)

MorningAfternoon
MRI Patient's Preferred Appointment Time (Select all that apply)

MorningAfternoonEvening
Patient Insurance Information
Insurance Policy
Policy Number
Policy Holder Name
Relationship to Policy Holder
Patient does not have insurance
Please verify that you are human*
Should be Empty:

Request an Appointment for Your Patient