Request an Appointment - American Health Imaging

Are you a new patient?*

Name*

First Last

Date of Birth*

Contact Phone 1*

Contact Phone 2

Email*

Briefly describe your diagnosis or enter your ICD (9) codes:*

Pick your state:

Which location would you like to visit?

Preferred Time 1

: HH

MM

Preferred Time 2

: HH

MM

Preferred Date

Do you have orders from your referring physician?

Physician Name

Physician Phone

What type of exam are you making an appointment for (see your physician's orders)?

Has your insurance changed since your last visit?

*

I understand that American Health Imaging cannot guarantee privacy for e‐mail communications over the internet, other than website submissions from Patient Portal. I understand and accept this risk, and thus, will allow American Health Imaging to communicate my protected health information on using my personal e-mail address listed above.