Rochester General Imaging Appointment Request Form - Rochester NY

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Rochester General Imaging

Phone: (585) 922-XRAY (9729)

Request An Imaging Appointment

Please use this form to request a non-urgent appointment only. Your request will be processed within 24 hours during regular business hours, Monday-Friday: 8:00 am - 6:00 pm. If you do not hear from us by phone or email to confirm your request or if you have questions about your appointment, please call us at (585) 922-XRAY (9729).

*** PLEASE NOTE: We cannot perform an imaging exam without a written requisition from your physician. Please contact your physician's office to obtain the proper requisition.

Appointments are not necessary for plain x-rays such as chest, leg or arm x-rays. These exams are available on a walk-in basis Monday-Friday: 8:00 am - 4:30 pm with a written request by your physician.

* = Required field

 

PATIENT INFORMATION

* First Name:

* Last Name:
* Date of Birth:
(mm/dd/yyyy)
Mailing Address:
City:
State:
Zip / Postal Code:
* Phone:

Alternate Phone:

* Email:
(valid email required)

* Please contact me by (check all that apply):


* Referring Physician Name:
Insurance Provider:
Policy Number:
 

APPOINTMENT INFORMATION

Exam Requested:




: If other, please specify:

Reason for Exam:

* Preferred Date:
(mm/dd/yyyy)
* Preferred Time:
Preferred Location:
Special Instructions:
 

TERMS OF USE

* By agreeing to the terms of use for online forms, you will enter a secure area of our site. Rochester General Imaging will be held harmless should your electronic message not be transmitted due to technical problems. Rochester General Imaging is HIPAA-compliant. Individually identifiable information is encrypted and your message will not be forwarded to other parties outside of our organization. The information will be used only by Rochester General Imaging.

 

PLEASE NOTE

You must accept the terms of use in order to process your request(s) online.