RADIOLOGY ROUTINE SCHEDULING REQUEST

Fields marked with an asterisk (*) are required.

Patient's First Name:

Patient's Middle Name:

Patient's Last Name:

Patient DOB:

DoD ID (xxxxxxxxxx):

Patient's Email:

Patient's Primary Phone (xxx-xxx-xxxx):

(optional) ext:

Patient's Secondary Phone (xxx-xxx-xxxx):

(optional) ext:

Sponsor's Last Four (xxxx):

Preferred Time To Contact You:

Preferred Study Date 1 (3 days later than today):

Preferred time for Study Date 1:

Preferred Study Date 2 (3 days later than Date 1):

Preferred time for Study Date 2:

Preferred Study Date 3 (3 days later than Date 2):

Preferred time for Study Date 3:

Type of Study:

Referring Institution:

Comments:

* Fluoroscopy includes barium, swallowing, sniff and HSG exams. *