Medical Records Request
Please note that your original radiology report will be faxed to your physician from a private radiology group within 3 to 5 business days. For updates on your results please contact your ordering physician. To retrieve those test results at no cost to you please contact your doctor or provider for the original complimentary copy of results.
Name
*
First Name
Last Name
Your Date of Birth
*
/
Month
/
Day
Year
Birthdate
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Exam Type Performed
*
Pelvic (non pregnant)
Pelvic and Transvaginal (non pregnant)
Transvaginal (non pregnant)
Fertility Scan (Uterine Lining)
Fertility Scan ( Ovaries/Follicle Tracking)
Abdomen
Abdomen Limited
Liver
Gallblabber
Kidneys (Renal)
Renal Doppler
Thyroid
Scrotum
Anatomy Scan (2nd/3rd Trimester Pregnancy)
Confirm My Pregnancy ( 6-12 weeks)
Biophysical Profile
Breast Imaging ( Ages under 35 years)
Breast Imaging ( Ages 35 + Plus)
Venous Doppler (One Leg)
Venous Doppler ( Both Legs)
Arterial Doppler (One Leg)
Arterial Doppler ( Two Legs
Carotid Doppler
Echocardiogram
Ankle Brachial Index
Prostate
Other
Date of Exam
-
Month
-
Day
Year
Date of Service
Report Request: (Delivered within 7-10 Business Days)
*
My doctor has discussed my results with me and I would like to request a personal copy of my ultrasound report for $35.
My doctor has NOT discussed my results with me and I would like to request a personal copy of my ultrasound report for $35.
Image Request: (Delivered within 7-10 Business Days)
I would like to request my ultrasound images. $0 (Ultrasound images are sent digitally through a secure image platform.)
I understand that there is a $35 fee to request a personal copy of my radiology report. This administrative fee is for the request of a (duplicate copy) from our Radiology Partners and will be available in 7-10 business days from the radiology group. * (Medical Images over 90 days have been archived and can take an additional 1-2 weeks to deliver).
Please verify that you are human
*
Submit Request
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