Chesapeake Imaging
CALL: 855-455-8900
SECURE FAX: 855-455-8222
REQUEST AN APPOINTMENT PAY MY BILL

Request an Appointment

Please complete the following form and submit,  note that all exam details and insurance information will be required before final scheduling is made.

  • INSURANCE INFORMATION

  • Health Insurance Plan Carrier (If this exam is related to a Work Injury or Auto Accident additional Information will be required)
  • IF not self
  • If other than self
  • IMAGING SERVICES

    Your Doctors order will indicate type of exam. If your Physician is ordering a STAT please call our office, do not request an appointment here.

  • Exam requested including laterality and if contrast is required
  • symptoms and/or diagnosis
  • An order must be provided from a Referring Provider
  • Appointment Info

    Instructions: Select two (2) preferred appointment dates. Please note that our scheduling hours are Monday-Friday from 8 am to 6 pm: Exam types and hours vary by Center/Location - see locations list below for details.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Disclaimer: You will be contacted as quickly as possible however please allow 24 business hours (M-F between 8am-6pm).  All insurance and ordering information will need to be received prior to appointment. We will do our best to accommodate your requested appointment date and time however this is not a confirmation of appointment.  We look forward to accommodating your imaging needs,and thank you for choosing Chesapeake Medical Imaging.

  • IMPORTANT INFORMATION

    IMPORTANT: Once you have submitted the information please do NOT call the office for the same purpose as this could cause duplicate appointments. You will be contacted by a CMI Scheduling Representative to confirm your final appointment date and time. Your request is not complete without a final confirmation.

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