Desert Imaging
Online Request

SERVICE REQUEST FORM

Thank you for submitting an online request to make an appointment. To schedule your appointment, you must have a medical provider’s referral. Please complete this form as thoroughly as possible. While insurance information is not required, providing it will expedite our ability to assist you. Fields marked with an asterisk (*) are required fields and need to be completed to send your request to Desert Imaging. Once your request is received, we will promptly contact you at the phone number(s) provided to arrange a visit.

When speaking with our associate, we encourage you to give us permission to use your email address to send you an appointment confirmation notice and to receive important news and announcements about Desert Imaging.

Thank you for choosing Desert Imaging! Because the sooner you know, the better.


PATIENT INFORMATION

Please provide your personal information.


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PHYSICIAN INFORMATION

Please provide the information about your referred physician:


APPOINTMENT PREFERENCE

Please note that we will schedule your service(s) for the date and time closest to your preferences.


* Required fields