Diagnostic Imaging Centers

Online Health Care Provider Scheduling Request Form

Please complete below information and then click "submit."

Your information will be forwarded to scheduling
and we will contact your patient.
If patient’s need is urgent please call scheduling at 913-344-9989 or 816-444-9989.

*Denotes required information

Patient Last Name*:

Patient Middle Initial:

Patient First Name*:

Patient Date of Birth*: format: 01/01/2001

Phone # to reach patient*: format: xxx-xxx-xxxx

Preferred time to call:

Patient Status:

Exam*:

Diagnosis*:

Authorization #

Name of Physician*: format: First Name, MI, Last Name

Name of person completing this form*:

*** Please fax written order

Scheduling Fax #’s: 913-344-9957 or 816-444-9957.
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