Request Input on a Case
This brief form provides a vehicle for you to request input from one of our radiologists day or night. If your request is received after hours, a radiologist will call you as soon as possible the following morning to answer your questions. If you would prefer to call, we encourage you to do so. A radiologist is always on-site during business hours. Click here for the phone number of the center nearest you.
* Required Fields

  Is this request urgent?:YES   NO
  If yes, STAT number to call:  
  Patient's first name:  
  Last name:  
  Date of birth:  
* Clinical history:  
  Prior EPIC Imaging studies: YES  NO  UNKNOWN
  Account or Rad # (optional):  
* Your differential diagnosis:  
  What imaging strategy do you propose?:  
* Please outline the points you would like to clarify or discuss with an EPIC Imaging radiologist:  
  Additional notes about films:  
  Name of Exam Ordered:  
  Do the films exist somewhere other than EPIC?
YES   NO
  If so, where can they be located?  
  Other information :  
* Your first name:  
* Your last name:  
* Your phone number:  
  Your email address: