Rochester General Imaging Requisition Request Form - Rochester NY

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Rochester General Imaging

Phone: (585) 922-XRAY (9729)

Request Requisitions

Rochester General Imaging offers a superior level of diagnostic, interventional and therapeutic services.

We request written requisitions to perform exams. Use the form below to request general diagnostic, MRI or PET/CT scan requisition forms.

Your request will be processed within 24 hours during regular business hours, Monday-Friday 8:00 am- 5:00 pm. If you do not hear from us by phone or email to confirm your request, please call us at (585) 922-XRAY (9729).

* = Required field

 

PROVIDER INFORMATION

* Provider Name:

* Practice Name:
Address and Suite:
City:
State:
Zip / Postal Code:
* Phone:
* Email:
(valid email required)

* Requisition Form Needed:
(CT Scan, MRI, X-ray)

* Quantity:
 

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.