Patient Medical Records Request

Please tell us who you are and give us a way to contact you:
Person to Contact:
Your e-mail address:
Your phone number: (ex: 239-000-0000)
First Name: Last Name:
Relationship to Patient:
Patient Information:
*First Name: *Last Name:
*Date of Birth: (ex: 09/09/1999)
*Daytime Phone # (ex:239-000-0000) Evening Phone# (ex:239-000-0000)
Appointment Information:
*Referring Physician:
*Diagnosis (Reason for Study):
*Study or Studies Requested:
Preferred Appointment Day: (select all that apply)
Monday Tuesday Wednesday Thursday Friday Saturday (MRI Only)
Preferable Appointment Time:

*Please note: Some appointment times/days are not available at all offices and in all modalities.

Please select the location you would like to be seen at:
600 Tarpon Bay Road, Sanibel (US, X-Ray)
63 Barkley Circle, Suites 100 & 101, Fort Myers (MRI, US, CT, X-Ray(Diagnostic & Fluoroscopy)
6311 South Pointe Boulevard, Suite 600, Fort Myers (MRI, US, CT, X-Ray, Nuclear Medicine, DEXA)

Comments:

You will be contacted by one of our friendly and knowledgeable schedulers during normal business hours, Monday through Friday 7:30AM-5PM. If you need to speak with someone right away, please call the scheduling department directly at 239-938-3535.

Questions