Patient Order Upload – Diagnostic Outpatient Imaging

Please fill out the following fields and upload a picture of your orders, ID and insurance.

First Name*
Last Name*
Date of Birth*
Cell Phone*
Email*
Referring Doctor*
Order Form/Prescription*
Max. file size: 200 MB.
Insurance Card (Front & Black)
Drop files here or

Max. file size: 516 MB, Max. files: 2.
Photo ID
Max. file size: 200 MB.
Example
(click to enlarge)
Other Documents
Drop files here or

Max. file size: 516 MB.
CAPTCHA
File
Max. file size: 516 MB.