Request an Appointment

Are you a NEW patient?*

Yes, I am a NEW patient.
No, I am an EXISTING patient.

First Name*

Last Name*

Date of Birth (ex. mm/dd/yyyy)*

MM

DD

YYYY

Phone*

Email*

Preferred Method of Contact*

Phone
Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

INSURANCE INFORMATION

Insurance Name*

Health Insurance Plan Carrier (If this exam is related to a Work Injury or Auto Accident additional Information will be required)

Member ID

Policy Holder

IF not self

Policy Holder DOB

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.

Choose Your Exam (select)*

Please Specify Exam Details as indicated on the order:

Exam requested including laterality and if contrast is required

Reason for Exam

symptoms and/or diagnosis

Ordering Physician*

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.

Appointment Location*

1st Preferred Date:*

2nd Preferred Date

Preferred Appointment Time

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.

Form validation - Please type below:

INSURANCE INFORMATION

IMAGING SERVICES

Appointment Info

IMPORTANT INFORMATION

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