Online Scheduling Request
You may order an exam online by completing the following information. An EPIC Imaging scheduler will call your patient within 24 hours to schedule an appointment.
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Required Fields
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Patient First Name:
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Last Name:
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Date of Birth:
MONTH
JAN
FEB
MAR
APR
MAY
JUN
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AUG
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OCT
NOV
DEC
DATE
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Patient's Work Phone Number:
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Patient's Home Phone Number:
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Please Contact:
PATIENT DIRECTLY
PHYSICIAN'S OFFICE
Physician's office contact name:
Also enter office contact number:
*
Best Time to Call:
PLEASE SELECT BEST TIME
MORNINGS
AFTERNOONS
Additional Contact Notes:
Are previous films available for this patient?
YES
NO
UNKNOWN
If yes, name of facility:
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1st Name of Physician Ordering Exam:
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Last Name of Physician:
Phone Number:
CC Physician:
*
Name of Exam:
PLEASE SELECT NAME OF EXAM
Multiple Exams
CT
MRI
Mammogram
Nuclear Medicine
PET
Ultrasound
X-ray
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Air Contrast-B.E.
Arthrogram
Barium Enema
DEXA Scan
Hysterosalpingogram
I.V. Pyleogram
Upper G.I.
Upper G.I. with Small Bowel Series
Voiding Cystourethrogram
Specify Body Area:
Please briefly describe the symptoms
that prompted this test:
Name of Patient's Insurance Co.:
Appointment Priority:
IMMEDIATE APPT. REQUIRED
NEXT AVAILABLE
Has a return appointment already been scheduled for this patient?
YES
NO
If yes, date of appointment:
MONTH
JAN
FEB
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
DATE
1
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TIME
8 AM
9 AM
10 AM
11 AM
12 PM
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
Time of appointment:
Reports are available in a variety of formats. Please select one:
Report only
Report and film
STAT Report
STAT number to call:
Fax Report
Fax number:
Please select the location your patient would prefer:
EPIC IMAGING|EAST
233 NE 102ND AVE.
PORTLAND
EPIC IMAGING|WEST
8950 SW NIMBUS AVE.
BEAVERTON
Note: if a PET Scan or nuclear medicine procedure is being ordered, your patient will be scheduled at the Portland PET Center located at 143 NE 102nd Ave., Portland, OR. Our scheduler will let your patient know if this applies to them.