Online Schedule Request
Requesting an online-appointment is not an actual appointment, our staff will be in contact to confirm time, date and exam requirements.
Patient Demographics
First Name *
Middle Name
Last Name *
Patient Address *
Zip Code *
Patient DOB *
Phone *
Email *
Exam Information
Washington Radiology - 100 Fulford Ave, Bel Air MD
Washington Radiology - 314 Franklin Avenue, Berlin MD
Washington Radiology - 1185 Imperial Drive, Hagerstown MD
Washington Radiology - 3300 Olney-Sandy Spring Rd, Olney MD
Washington Radiology - 1820 SweetBay Dr., Salisbury MD
Location *
Select A Location For Available Exam Types...
Preferred Date *
This is preferred date not an actual schedule date/time. We will contact you to confirm availability.
Select Date First...
Available Date/Times *
Body Part Being Scanned (e.g. MRI Left Knee) *
Referring Physican *
Referring Phone *
Insurance Name
Insurance Policy #
Insurance Group #
Insurance Address
Access Issues
Is patient prone to slips, trips or falls?
Can the patient stand unassisted for a minium of 10 minutes?
If you answered No to the previous question, please select the support needed for patient:
Cane
Walker
Wheelchair
Additional Person
Hoyer Lift
None
Other
I Have a Physician Order
Add More Files
Submit Schedule Request
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Upload Referral Request
Drop Request PDF/Image Here:
