Request Appointment
Please complete the form below and a scheduler will contact you within 24 hours to confirm your appointment.
If you would like immediate assistance, please call
317-972-9669
or
800-400-XRAY (9729)
option 2, Mon. - Fri., 8 am - 5 pm.
Walk-Ins ONLY for general x-rays. No appointments are scheduled. Bring your doctor’s order to one of our imaging centers.
Appointment Request Form
Appointment Requested by:
Patient
Physician
Referring Physician:
First Name:
Last Name:
Date of Birth:
Email:
Primary Phone Number:
Secondary Phone Number:
Alternate Phone Number:
1st Choice Preferred Date:
2nd Choice Preferred Date:
Preferred Time for Appointment:
Preferred Method of Contact:
-- Select A Contact Method --
Primary Phone Number
Secondary Phone Number
Email
Preferred Location:
-- Select A Location --
NWR Breast Center
10603 North Meridian Street Imaging Center
Meridian North Imaging Center
Type of Procedure:
-- Select A Procedure --
Biopsy
Bone Density/Osteoporosis Study, DEXA
CT Scan
Mammography
MRI
Nuclear Medicine
Ultrasonography
PET CT
Symptoms or Reason for Exam:
Captcha
Please let us know if you have had previous mammography elsewhere.
If you can bring these films with you, this would be very helpful. Otherwise, we will be happy to request the outside mammogram by mail delivery.
If you need to cancel your appointment, we would greatly appreciate if you would provide 24 hours notice.
Submit
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