Requesting imaging for your patient is easy. Simply print out the form, make your selections, and sign it.
Below are some options for sending it to us:
- Fax it to us at (386) 280-0081
- Contact us for a compliant electronic method of transfer.
- Have the patient bring it to us in person
- More options will be available soon. Feel free to contact us.
NOTE: Please include a copy of the insurance card and patient contact information.
Click here to print the prescription form.
(Print multiple copies to have on hand.)
Click here to request delivery of more prescription pads.
Thank you.