THIS IS ONLY AN APPOINTMENT REQUEST. A scheduler from Northwest Radiology will call you within 1 business day to schedule your appointment according to what time slots are available for your type of exam. We will make every effort to schedule your appointment as close to your requested time as possible. Your exam is NOT scheduled until confirmed via phone by Northwest Radiology.  

If you would like to schedule a same day appointment or schedule a confirmed appointment immediately, please call 317-972-9669 or 800-400-9729 option 2.

* Required Fields

Appointment Scheduled by* Patient  Physician
Patient's Name*
Primary Phone #* Home  Work  Cellular *
Secondary Phone #* Home  Work  Cellular *
Alternate Phone #* Home  Work  Cellular *
   
Appointment  
Location*
1st Choice Date / Time*  
2nd Choice Date / Time*  
   
Referring Physician*
Exam Needed*
Reason for Exam or Symptoms*
E-mail address
   
What is your contact preference?* Home  Work  Cellular