Request an Appointment

Are you a new patient?*
- Yes
- No
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
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?
Which location would you like to visit?
Which location would you like to visit?
Which location would you like to visit?
Which location would you like to visit?
Which location would you like to visit?
Preferred Time 1

: Hours

Minutes

AM/PM
Preferred Time 2

: Hours

Minutes

AM/PM
Preferred Date
MM slash DD slash YYYY
Do you have orders from your referring physician?
- Yes
- No
Physician Name
Physician Phone
What type of exam are you making an appointment for (see your physician's orders)?
What type of exam are you making an appointment for (see your physician's orders)?
What type of exam are you making an appointment for (see your physician's orders)?
Has your insurance changed since your last visit?
- Yes
- No
*
- 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.
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