Request an Appointment

Please complete the form below and a scheduler will contact you within 1-2 business days to confirm your appointment. A doctor's order must be faxed to us in order to schedule any appointment other than a screening mammogram or x-ray. If you would like immediate assistance, please call 317-972-9669 or 800-400-9729 option 2, Mon. – Fri. 8 am – 5 pm.

*Appointment Requested by:
Patient
Physician

*First Name:

*Last Name:

*Date of Birth:

*Email Address:

*Primary Phone:

*Alternate Phone:

*Preferred Contact Method:
Phone
Email

*Type of Exam(s) Needed (check all that apply):

DEXA Bone Density

MRI

Mammogram

Nuclear Medicine

PET/CT

UltraSound

*Preferred Location:

No Preference

*Preferred Date:

*Alternate Date:

*Preferred Time:

Early Morning
Mid Morning
Afternoon
Evening
Any Time

*Symptoms / Reason for Exam:

*Health Insurance Provider:

*Policy Number:

Upload a photo or scan of your insurance card. (optional)

*Front of Card:

*Back of Card:

*Do you have a doctor's order?
Yes
No

Doctor's order is required for all appointments except screening mammograms.

*Referring Provider's Name:

If you need to cancel your appointment, we would greatly appreciate if you would provide 24 hours notice.