Printable Provider Order Form (PDF)
Exam order form in printable PDF format. Upon completion:
- Fax to: 1-855-455-8222 –OR- firstname.lastname@example.org
- Give to the patient for their appointment.
Click for Ordering Guides (password applies).
Chesapeake Medical Imaging continues to remain steadfast in following CDC guidelines to prevent the spread of COVID-19.
Inside our locations we are requiring social distancing, limiting the number of patients in the waiting rooms, wearing of masks by both patients and staff, and screening at the time of scheduling and arrival to ensure we mitigate exposure inside our locations.
We are happy to continue supporting our community partners, providers and patients by remaining proactive and taking all necessary precautions. We continue to offer same day appointments when available and remind patients of our multiple locations in which we can serve them conveniently and safely.