Schedule Appointment Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.I am: *New PatientReturning PatientName *FirstMiddleLastDate of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone (Cell Preferred)Email *Type of Exam(s) *High Field MRIHigh Field Wide Bore MRIHigh Field Open MRIMRA | MRV | MRCPEchocardiogramArthrogramDTI | SWINeuroQuantUltrasound3D MammogramBreast MRIDEXA - Bone DensityCT ScanDigital X-RayPreferred Facility *Please choose facilityPalm Harbor MRIHighland MRI (Lakeland)Winter Haven MRIBrandon MRISarasota MRIBradenton MRIVenice MRIVenice MRI - Port CharlottePreferred Facility *Please choose facilityPalm Harbor MRIBrandon MRIHighland MRI (Lakeland)Venice MRI - Port CharlottePreferred Facility *Please choose facilitySarasota MRIPreferred Facility *Please choose facilityPalm Harbor MRIHighland MRI (Lakeland)Winter Haven MRISarasota MRIBrandon MRIBradenton MRIVenice MRIVenice MRI - Port CharlottePreferred Facility *Please choose facilityPalm Harbor MRIPreferred Facility *Please choose facilityPalm Harbor MRISarasota MRIPreferred Facility *Please choose facilityPalm Harbor MRIHighland MRI (Lakeland)Winter Haven MRIBrandon MRISarasota MRIVenice MRIVenice MRI - Port CharlottePreferred Facility *Please choose facilityPalm Harbor MRIWinter Haven MRIBrandon MRISarasota MRIPreferred Facility *Please choose facilityPalm Harbor MRIHighland MRI (Lakeland)Winter Haven MRIBrandon MRISarasota MRIVenice MRIPreferred Facility *Please choose facilityPalm Harbor MRIWinter Haven MRIBrandon MRIPreferred Facility *Please choose facilityBrandon MRIPreferred Facility *Please choose facilityBrandon MRIPreferred Facility *Please choose facilityPalm Harbor MRIHighland MRI (Lakeland)Winter Haven MRIBrandon MRISarasota MRIVenice MRIReferring PhysicianUpload Photo of Insurance Card (Front and Back) or Enter Insurance Information Below Click or drag a file to this area to upload. Simply take a photo of insurance card (front and back), then upload the photos above.Primary InsurancePrimary Insurance ID NumberSecondary InsuranceSecondary Primary Insurance ID NumberIs this Workers Comp or Automotive Accident Related?YesNoWhich Type of Accident?Workers CompAutomobile AccidentPreferred Exam DatePlease be sure to allow 3 business days for authorization processPreferred Exam DateExam Time Preference 7:00 am to 11:00 am11:00 am to 3:00 pm3:00 pm to 7:00 pmAfter 7:00 pmI have a scriptYesNoUpload Script (If Possible) Click or drag files to this area to upload. You can upload up to 3 files. Simply take a photo of the script then upload the photo above.Preferred LanguageEnglishSpanishComment or MessageMessageRequest Appointment
