Chesapeake Imaging
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CALL: 855-455-8900
SECURE FAX: 855-455-8222
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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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