Screening Appointment Request
Reason for Request
Request an appointment
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
example@example.com
WHICH SCREENING WOULD YOU LIKE TO BOOK?
*
MAMMOGRAM SCREENING (Walk ins available)
MAMMOGRAM SCREENING WITH AI ADD ON $49 (Walk ins available)
WHOLE BODY MRI EXPRESS (30 MIN EXAM) $795
WHOLE BODY MRI (60 MIN EXAM) $1250
WHOLE BODY MRI (60 MIN EXAM + LUNGS(CT scan) $1575
HEART SCORE (CARDIAC CT SCAN) $200
LUNG SCREENING (CHEST/LUNGS) $325
OTHER MODALITY/Exams
Other Modality/ Exams (requires a physician's order from your established healthcare provider)
MRI - Magnetic Resonance Imaging
CT - Computed Tomography
US - Ultrasound - General
MG -Diagnostic Mammogram/ and Breast Ultrasound Mammogram
DX - Dexa
X-ray are on walking base (8-5pm M-F)
Fluro - Procedure
Name of the exam (s)
Preferred Time of Day
Morning
Afternoon
Anytime
Preferred Day of the Week
Any day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Physician name (PCP)
*
First Name
Last Name
Physician Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Comments or Instructions
Do you have any files or documents related to the selected exam that you would like to upload?
*
Yes
No
please upload
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