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.)