Skip to content
Toggle Navigation
Home
For Patients
Patients Home
How It Works
Imaging Center Locator
Locations by City
Virtual Consultations
Program Details
MRI
CT Scan
Ultrasound
X-Ray
Mammogram
PET Scan
Resources
FAQ
Contact us
For Providers
Providers home
Refer a Patient
Join partner program
For Organizations
Organizations Home
How it works
Schedule Now
Toggle Navigation
Off Canvas Toggle
Virtual Consultation Form
Jaswinder Singh
2025-05-26T16:38:22-06:00
Appointments : 855-346-5152
Toggle Navigation
How It Works
Imaging Center Locator
Virtual Consultations
Resources
FAQ
Virtual Consultation Service
You are being scheduled for a
consultation
What is a virtual consult?
In a virtual consult, a licensed provider will write an imaging order based on a virtual visit. A cirtual consultation does not include a call and does not always allow for a back and forth discussion like a regular consult so you must be detailed and specific with your request.
What are the pros and cons of a virtual consult?
A virtual consult is faster and lower cost than a traditional consult where a provider meets with a patient in-person. However, it is often not a good choice when the patient needs advice that requires a back and forth discussion.
How long will it take to get a response?
Providers will respond within 1 business day. For example : a consult submitted at 10am on Monday, will be completed by 5pm Tuesday. Do not use this service in case of an emergency.
*
I understand that a provider will write an imaging order without a phone call.
*
I understand that referrals are based on medical necessity guidelines. The medical provider could determine that an alternate type of study is needed.
*
There is no guarantee that RadiologyAssist can actually schedule the order written. No refunds will be provided.
Patient Information
Patient Name
*
Please enter exactly as on your id. The name on the order can not be changed once issued.
First
Last
Date of birth
*
Please enter exactly as on your id. It can not be changed later.
Date Format: MM slash DD slash YYYY
Is the patient a minor (under the age of 18)?
*
Yes
No
Legal Guardian Name
*
For patient under 18, the request must be completed and signed by the legal guardian.
First
Last
Gender
*
Male
Female
Phone
*
Provider will call you at this number. Please ensure it is accurate and you are reachable at this number.
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
We are currently unable to provide a virtual consultation in your state.
Consultation Type
Is this a follow up to a previous virtual consultation you completed?
Yes
No
Synchronous Consultation Selected
Since you need to speak with a provider, we will schedule you for a synchronous consultation. You will receive email instructions with a login to initiate an instant chat with a provider. You will need to upload your reports in the chat and will have 5 days to complete the consult. Do not submit a request until you have your reports ready.
The cost of this follow up consult is $40.
RadiologyAssist is unable to obtain reports for you.
Requested Imaging Study
I am unsure what study is needed. Let the provider determine the appropriate imaging study for me
Imaging Studies Requested
*
As Per Provider Preference
I do not know what study I need
MRI - As Per Provider Preference
CT Scan - As Per Provider Preference
Ultrasound - As Per Provider Preference
Xray - As Per Provider Preference
DEXA - As Per Provider Preference
74181 - MRI - Abdomen - Without Contrast
74183 - MRI - Abdomen - With & Without Contrast
73221 - MRI - Upper Extremity Joint - Without Contrast
73223 - MRI - Upper Extremity Joint - With & Without Contrast
73218 - MRI - Upper Extremity Non Joint - Without Contrast
73220 - MRI - Upper Extremity Non Joint - With & Without Contrast
73721 - MRI - Lower Extremity Joint - Without Contrast
73723 - MRI - Lower Extremity Joint - With & Without Contrast
73718 - MRI - Lower Extremity - Without Contrast
73720 - MRI - Lower Extremity - With & Without Contrast
73721 - MRI - Ankle - Without Contrast
73723 - MRI - Ankle - With & Without Contrast
"73615, 73722, 27648 - MRI - Ankle - Arthrogram"
"73615, 73722, 27648 - MRI - Arthrogram - Ankle (Unilateral)"
"73115, 73222, 25246 - MRI - Arthrogram - Wrist (Unilateral)"
"70336, 77002, 21161 - MRI - Arthrogram - TMJ"
"73040, 73222, 23350 - MRI - Arthrogram - Shoulder (Unilateral)"
"73580, 73722, 27369 - MRI - Arthrogram - Knee (Unilateral)"
"73525, 73722, 27093 - MRI - Arthrogram - Hip (Unilateral)"
"73085, 73222, 24220 - MRI - Arthrogram - ELbow (Unilateral)"
70551 - MRI - Brain - Without Contrast
70553 - MRI - Brain - With & Without Contrast
"70553, 70553 - MRI - Brain with Pituitary - With & Without Contrast"
70551 - MRI - Internal Auditory Canal (IAC) - Without Contrast
70553 - MRI - Internal Auditory Canal (IAC) - With & Without Contrast
"70553, 70553 - MRI - Brain and Pituitary - With & Without Contrast"
77046 - MRI - Breast - Unilateral - Without Contrast
77048 - MRI - Breast - Unilateral - With & Without Contrast
77047 - MRI - Breast - Bilateral - Without Contrast
77049 - MRI - Breast - Bilateral - With & Without Contrast
72156 - MRI - Cervical Spine - With & Without Contrast
72141 - MRI - Cervical Spine - Without Contrast
71552 - MRI - Chest/Thorax - With & Without Contrast
71550 - MRI - Chest/Thorax - Without Contrast
74181 - MRI - Cholangiopancreatography - Without Contrast
73223 - MRI - Elbow - With & Without Contrast
73221 - MRI - Elbow - Without Contrast
"73085, 73222, 24220 - MRI - Elbow - Arthrogram"
"74183, 72197 - MRI - Enterography - With & Without Contrast"
73720 - MRI - Foot - With & Without Contrast
73718 - MRI - Foot - Without Contrast
73218 - MRI - Hand - Without Contrast
73220 - MRI - Hand - With & Without Contrast
73218 - MRI - Forearm - Without Contrast
73220 - MRI - Forearm - With & Without Contrast
73218 - MRI - Humerus - Without Contrast
73220 - MRI - Humerus - With & Without Contrast
73723 - MRI - Hip - Unilateral - With & Without Contrast
73721 - MRI - Hip - Unilateral - Without Contrast
"73723, 73723 - MRI - Hip - Bilateral - With & Without Contrast"
"73721, 73721 - MRI - Hip - Bilateral - Without Contrast"
"73525, 73722, 27093 - MRI - Hip - Unilateral - Arthrogram"
73723 - MRI - Knee - Unilateral - With & Without Contrast
73721 - MRI - Knee - Unilateral - Without Contrast
73723 - MRI - Knee (Left) - Unilateral - With & Without Contrast
73721 - MRI - Knee (Left) - Unilateral - Without Contrast
73723 - MRI - Knee (Right) - Unilateral - With & Without Contrast
73721 - MRI - Knee (Right) - Unilateral - Without Contrast
73723 - MRI - Knee (Unspecified) - Unilateral - With & Without Contrast
73721 - MRI - Knee (Unspecified) - Unilateral - Without Contrast
"73723, 73723 - MRI - Knee - Bilateral - With & Without Contrast"
"73721, 73723 - MRI - Knee - Bilateral - Without Contrast"
"73580, 73722, 27369 - MRI - Knee - Unilateral - Arthrogram"
73720 - MRI - Lower Leg - With & Without Contrast
73718 - MRI - Lower Leg - Without Contrast
72158 - MRI - Lumbar Spine - With & Without Contrast
72148 - MRI - Lumbar Spine - Without Contrast
70540 - MRI - Orbit / Face / Neck - Without Contrast
70543 - MRI - Orbit / Face / Neck - With & Without Contrast
70540 - MRI - Face - Without Contrast
70543 - MRI - Face - With & Without Contrast
70540 - MRI - Neck - Without Contrast
70543 - MRI - Neck - With & Without Contrast
72197 - MRI - Pelvis - With & Without Contrast
72195 - MRI - Pelvis - Without Contrast
73223 - MRI - Shoulder - With & Without Contrast
73221 - MRI - Shoulder - Without Contrast
"73040, 73222, 23350 - MRI - Shoulder - Arthrogram"
73720 - MRI - Thigh - With & Without Contrast
73718 - MRI - Thigh - Without Contrast
72157 - MRI - Thoracic Spine - With & Without Contrast
72146 - MRI - Thoracic Spine - Without Contrast
70336 - MRI - TMJ - With & Without Contrast
"70336, 77002, 21161 - MRI - TMJ - Arthrogram"
73223 - MRI - Wrist - With & Without Contrast
73221 - MRI - Wrist - Without Contrast
"73115, 73222, 25246 - MRI - Wrist - Arthrogram"
74176 - CT Scan - Abdomen & Pelvis - Without Contrast
74178 - CT Scan - Abdomen & Pelvis - With & Without Contrast
74174 - CT Scan - Abdomen & Pelvis - Angiogram
74150 - CT Scan - Abdomen - Without Contrast
74170 - CT Scan - Abdomen - With & Without Contrast
74175 - CT Scan - Abdomen - Angiogram
73700 - CT Scan - Ankle - Without Contrast
73702 - CT Scan - Ankle - With & Without Contrast
73706 - CT Scan - Ankle - Angiogram
"73701, 77002, 27648 - CT Scan - Ankle - Arthrogram"
74175 - CT Scan - Angiogram - Abdomen
74174 - CT Scan - Angiogram - Abdomen & Pelvis
70496 - CT Scan - Angiogram - Head / Brain
70496 - CT Scan - Angiogram - Brain
70498 - CT Scan - Angiogram - Carotids
71275 - CT Scan - Angiogram - Chest
75574 - CT Scan - Angiogram - Heart / Coronaries
73706 - CT Scan - Angiogram - Lower Extremity
70498 - CT Scan - Angiogram - Neck
72191 - CT Scan - Angiogram - Pelvic
75572 - CT Scan - Angiogram - Pulmonary
74175 - CT Scan - Angiogram - Renal
75635 - CT Scan - Angiogram - Run-Offs
73206 - CT Scan - Angiogram - Upper Extremity
70450 - CT Scan - Brain - Without Contrast
70460 - CT Scan - Brain - With Contrast
70470 - CT Scan - Brain - With & Without Contrast
70496 - CT Scan - Brain - Angiogram
75571 - CT Scan - Calcium Score - Without Contrast
71250 - CT Scan - Chest - Without Contrast
71260 - CT Scan - Chest - With Contrast
71270 - CT Scan - Chest - With & Without Contrast
71275 - CT Scan - Chest - Angiogram
72125 - CT Scan - Cervical Spine - Without Contrast
72126 - CT Scan - Cervical Spine - With Contrast
72127 - CT Scan - Cervical Spine - With & Without Contrast
74177 - CT Scan - Enterography - Without Contrast
70450 - CT Scan - Head - Without Contrast
70460 - CT Scan - Head - With Contrast
70470 - CT Scan - Head - With & Without Contrast
70496 - CT Scan - Head - Angiogram
73700 - CT Scan - Lower Extremity - Without Contrast
73701 - CT Scan - Lower Extremity - With Contrast
73702 - CT Scan - Lower Extremity - With & Without Contrast
73706 - CT Scan - Lower Extremity - Angiogram
72131 - CT Scan - Lumbar Spine - Without Contrast
72132 - CT Scan - Lumbar Spine - With Contrast
72133 - CT Scan - Lumbar Spine - With & Without Contrast
70486 - CT Scan - Maxillofacial - Without Contrast
70487 - CT Scan - Maxillofacial - With Contrast
70488 - CT Scan - Maxillofacial - With & Without Contrast
72192 - CT Scan - Pelvis - Without Contrast
72193 - CT Scan - Pelvis - With Contrast
72194 - CT Scan - Pelvis - With & Without Contrast
72191 - CT Scan - Pelvis - Angiogram
70490 - CT Scan - Neck - Without Contrast
70491 - CT Scan - Neck - With Contrast
70492 - CT Scan - Neck - With & Without Contrast
70498 - CT Scan - Neck - Angiogram
70480 - CT Scan - Orbits / Sella / Iacs - Without Contrast
70481 - CT Scan - Orbits / Sella / Iacs - With Contrast
70482 - CT Scan - Orbits / Sella / Iacs - With & Without Contrast
70486 - CT Scan - Sinus - Complete Without Contrast
72128 - CT Scan - Thoracic Spine - Without Contrast
72129 - CT Scan - Thoracic Spine - With Contrast
72130 - CT Scan - Thoracic Spine - With & Without Contrast
73200 - CT Scan - Upper Extremity - Without Contrast
73201 - CT Scan - Upper Extremity - With Contrast
73202 - CT Scan - Upper Extremity - With & Without Contrast
73206 - CT Scan - Upper Extremity - Angiogram
74178 - CT Scan - Urogram - With & Without Contrast
G0297 - CT Scan - Lungs - Cancer Screening - Low Dose
71271 - CT Scan - Lungs - Cancer Screening - Low Dose
75571 - CT Scan - Coronary Screening - Low Dose
77073 - CT Scan - Scanogram-Leg lengths - Scanogram-Leg lengths
76700 - Ultrasound - Abdomen - Complete
76705 - Ultrasound - Abdomen - Limited - Single Organ / Quadrant or follow up
"76700, 76856 - Ultrasound - Abdomen & Pelvis - w/o Transvaginal"
"76700, 76856, 76830 - Ultrasound - Abdomen & Pelvis - With Transvaginal"
76882 - Ultrasound - Axilla - Complete
76641 - Ultrasound - Breast (Unilateral)
7699A - Ultrasound - Buttock - Complete
93880 - Ultrasound - Carotid - Carotid
76604 - Ultrasound - Chest - Pleural Effusion Fluid in Chest or Soft Tissue
76604 - Ultrasound - Chest Wall - Complete
76856 - Ultrasound - Pelvis - Pelvic Complete
76856 - Ultrasound - Genitalia (Male) - Prostate (Non-transrectal)
76870 - Ultrasound - Genitalia (Male) - Scrotum and Contents (Testicles)
76882 - Ultrasound - Groin (Hip Groin Region & Peripheral Nerves) - Complete
76536 - Ultrasound - Head / Neck - Soft Tissues (Thyroid Parathyroid Parotid)
76770 - Ultrasound - Kidney / Renal - Complete
93975 - Ultrasound - Doppler - Complete
93976 - Ultrasound - Doppler - Limited
76801 - Ultrasound - Ob/Gyn - 1st Trimester <14 weeks
76805 - Ultrasound - Ob/Gyn - 2nd & 3rd Trimester >14weeks
76815 - Ultrasound - Ob/Gyn - OB Limited (Fetal heartbeat Placental & Fetal Position)
76816 - Ultrasound - Ob/Gyn - OB Follow Up (Re-Evaluate Fetal Size & Organ Sys)
76857 - Ultrasound - Pelvic Wall - Complete
76857 - Ultrasound - Pelvis - Bladder Only
76830 - Ultrasound - Transvaginal - Transvaginal (Non-Obstetric)
"76856, 76830 - Ultrasound - Pelvis and Transvaginal - Complete"
"76856, 76830, 93975 - Ultrasound - Pelvis and Transvaginal with Doppler"
76800 - Ultrasound - Spine - Spinal Canal & Contents
76870 - Ultrasound - Testicular / Scrotal - Testicular / Scrotal
"76870, 93975 - Ultrasound - Testicular / Scrotal with Doppler (Complete)"
"76870, 93976 - Ultrasound - Testicular / Scrotal with Doppler (Limited)"
76881 - Ultrasound - Upper & Lower Extremities - Complete
93925 - Ultrasound - Arterial - Bilateral
93926 - Ultrasound - Arterial - Unilateral
93971 - Ultrasound - Venous - Unilateral
93970 - Ultrasound - Venous - Bilateral
76700 - Ultrasound - Liver - Complete
76700 - Ultrasound - Pancreas - Complete
76700 - Ultrasound - Aorta - Complete
76700 - Ultrasound - Galbladder - Complete
76857 - Ultrasound - Bladder - Complete
"76942, 10021 - Ultrasound - Fine Needle Aspiration w/imag - Complete"
"76942, 10160 - Ultrasound - Neck Abscess Drainage by needle - Complete"
70100 - Xray - Mandible - 3 Views
70110 - Xray - Mandible - 4+ Views
70120 - Xray - Mastoids - 2 Views
70130 - Xray - Mastoids - 3 Views
70140 - Xray - Facial Bones - 2 Views
70150 - Xray - Facial Bones - 3 Views
70160 - Xray - Nasal Bones - 3 Views
70200 - Xray - Orbits / Sella / Iacs - 4+ Views
70210 - Xray - Sinuses/ Paranasal - 2 Views
70220 - Xray - Sinuses/ Paranasal - 3 Views
70250 - Xray - Skull - 3 Views
70260 - Xray - Skull - 4+ Views
70330 - Xray - Temporomandibular Joint Open/Closed Bilateral - 1 View
70360 - Xray - Neck Soft Tissue - 1 Views
71045 - Xray - Chest - 1 View
71046 - Xray - Chest - 2 Views
71047 - Xray - Chest - 3 Views
71048 - Xray - Chest - 4+ Views
71100 - Xray - Ribs Unilateral - 2 Views
71101 - Xray - Ribs Unilateral - 3 Views
71110 - Xray - Ribs Bilateral - 3 Views
71111 - Xray - Ribs Bilateral - 4+ Views
71120 - Xray - Sternum - 2 Views
71130 - Xray - Sternum - 3 Views
72020 - Xray - Spine Single View Specify Level (Scoliosis) - 1 View
72040 - Xray - Cervical Spine - 3 Views
72050 - Xray - Cervical Spine - 4 Views
72052 - Xray - Cervical Spine - Complete
72070 - Xray - Thoracic - 2 Views
72072 - Xray - Thoracic - 3 Views
72074 - Xray - Thoracic - 4 Views
72080 - Xray - Thoracolumbar Junction - 2 Views
72081 - Xray - Spine Scoliosis Study Incl. Supine & Erect - 1 View
72082 - Xray - Spine Scoliosis Study Incl. Supine & Erect - 2 Views
72082 - Xray - Spine Scoliosis Study Incl. Supine & Erect - 3 Views
72083 - Xray - Spine Scoliosis Study Incl. Supine & Erect - 4 Views
72084 - Xray - Spine Scoliosis Study Incl. Supine & Erect - 6+ Views
72100 - Xray - Lumbar Spine (Lumbosacral) - 2 Views
72100 - Xray - Lumbar Spine (Lumbosacral)- 3 Views
72110 - Xray - Lumbar Spine (Lumbosacral) - 4+ Views
72114 - Xray - Lumbar Spine (Lumbosacral) Complete Incl. Bending Views - 4+ Views
72120 - Xray - Lumbar Spine (Lumbosacral) Bending Views Only - 2 Views
72120 - Xray - Lumbar Spine (Lumbosacral) Bending Views Only - 3 Views
72170 - Xray - Pelvis - 1 View
72170 - Xray - Pelvis - 2 Views
72200 - Xray - Sacroiliac Joints - 2 Views
72202 - Xray - Sacroiliac Joints - 3 Views
72220 - Xray - Sacrum & Coccyx - 2 Views
73000 - Xray - Clavicle Complete - 1 View
73010 - Xray - Scapula Complete - 2 Views
73020 - Xray - Shoulder - 1 View
73030 - Xray - Shoulder - 2 Views
73050 - Xray - Acromioclavicular Joint Bilat w/ or w/o Weights - Acromioclavicular Joint Bilat w/ or w/o Weights
73060 - Xray - Humerus - 3 Views
73070 - Xray - Elbow - 1 View
73080 - Xray - Elbow - 2 Views
73090 - Xray - Forearm - 1 View
73100 - Xray - Wrist - 2 Views
73110 - Xray - Wrist - 3 Views
73120 - Xray - Hand - 2 Views
73130 - Xray - Hand - 3 Views
"73120, 73120 - Xray - Hand Bilateral - 2 Views"
"73130, 73130 - Xray - Hand Bilateral - 3 Views"
73140 - Xray - Fingers - 1 View
73501 - Xray - Hip Unilateral Incl AP of Pelvis - 1 View
73502 - Xray - Hip Unilateral Incl AP of Pelvis - 2 Views
73502 - Xray - Hip Unilateral Incl AP of Pelvis - 3 Views
73503 - Xray - Hip Unilateral Incl AP of Pelvis - 4 Views
73521 - Xray - Hip Bilateral Incl. AP of Pelvis - 2 Views
73522 - Xray - Hip Bilateral Incl. AP of Pelvis - 3 Views
73522 - Xray - Hip Bilateral Incl. AP of Pelvis - 4 Views
73523 - Xray - Hip Bilateral Incl. AP of Pelvis - 5 Views
73551 - Xray - Femur - 1 View
73552 - Xray - Femur - 2 Views
73560 - Xray - Knee Single - 1 or 2 Views
73562 - Xray - Knee Single - 3 Views
73564 - Xray - Knee Single - 4 Views
"73560, 73560 - Xray - Knee Both - 1 or 2 Views"
"73562, 73562 - Xray - Knee Both - 3 Views"
"73564, 73564 - Xray - Knee Both - 4 Views"
73590 - Xray - Tibia & Fibula - 2 Views
73600 - Xray - Ankle - 2 Views
73610 - Xray - Ankle - 3 Views
73620 - Xray - Foot - 2 Views
73630 - Xray - Foot - 3 Views
"73620, 73620 - Xray - Foot Bilateral - 2 Views"
"73630, 73630 - Xray - Foot Bilateral - 3 Views"
73650 - Xray - Calcaneus or Heel - 2 Views
73660 - Xray - Toe(s) - 2 Views
74018 - Xray - Abdomen - 1 View
74019 - Xray - Abdomen - 2 Views
74021 - Xray - Abdomen - 3+ Views
74022 - Xray - Abdomen - Abdomen Complete Acute Abdomen Series 1 Chest View
77072 - Xray - Bone & Joints - Bone Age Studies
77073 - Xray - Bone & Joints - Bone Length Studies (Scanogram / Orthoroentgenogram)
77075 - Xray - Bone & Joints - Bone Survey
74240 - Xray - Upper GI Tract - w/o KUB
74241 - Xray - Upper GI Tract - with KUB
74245 - Xray - Upper GI Tract - with small intestine
74247 - Xray - Upper GI Tract - Contrast with KUB
74246 - Xray - Upper GI Tract - Contrast w/o KUB
74175 - CTA - Angiogram Abdomen - With & Without Contrast
74174 - CTA - Angiogram Abdomen & Pelvis - With & Without Contrast
70496 - CTA - Angiogram Head / Brain - With & Without Contrast
70498 - CTA - Angiogram Carotids - With & Without Contrast
71275 - CTA - Angiogram Chest - With & Without Contrast
75574 - CTA - Angiogram Heart / Coronaries - Angiogram Heart / Coronaries
73706 - CTA - Angiogram Lower Extremity - Angiogram Lower Extremity
70498 - CTA - Angiogram Neck - Angiogram Neck
72191 - CTA - Angiogram Pelvic - Angiogram Pelvic
75572 - CTA - Angiogram Pulmonary - Angiogram Pulmonary
74175 - CTA - Angiogram Renal - With & Without Contrast
75635 - CTA - Angiogram Run-Offs - With & Without Contrast
73206 - CTA - Angiogram Upper Extremities - Angiogram Upper Extremities
74185 - MRA - Abdomen Angio - Abdomen
71555 - MRA - Chest / Thorax Angio - Chest / Thorax
70546 - MRA - Head / Brain Angio - With & Without Contrast
70545 - MRA - Head / Brain Angio - With Contrast
70544 - MRA - Head / Brain Angio - Without Contrast
73725 - MRA - Lower Extremity Angio - Lower Extremity
70549 - MRA - Neck / Carotid Angio - With & Without Contrast
70548 - MRA - Neck / Carotid Angio - With Contrast
70547 - MRA - Neck / Carotid Angio - Without Contrast
72198 - MRA - Pelvis Angio - Pelvis
72159 - MRA - Spine / Spinal Canal Angio - Spine
73225 - MRA - Upper Extremity Angio - Upper Extremity
74262 - Virtual Colonoscopy - Virtual Colonoscopy Diagnostic - With Contrast
74261 - Virtual Colonoscopy - Virtual Colonoscopy Diagnostic - Without Contrast
"77067, 77063 - Screening Mammogram"
"77065, 76641 - Diagnostic Mammogram with Breast Ultrasound if needed (Unilateral)"
"77066, 76641, 76641 - Diagnostic Mammogram with Breast Ultrasound if needed (Bilateral)"
77080 - DEXA - Bone Density / DEXA - Bone Density / DEXA
74181 - MRCP (Abdomen, Liver, Pancreas)
Select your best guess or enter "As Per Provider Preference" under Imaging Studies Requested.
Any special protocols or notes for the studies selected?
For lateral studies, which side?
*
Left
Right
Both (Bilateral)
N/A
Reason For Study
Please provide a detailed explanation about the reason for the request
*
Note : Please be as detailed as possible. The provider will make a medical decision based on your written narrative. Also please include any pertinent information about why the study you are asking for is appropriate.
Follow Up
What are your plans for follow up?
*
I will follow up with my own provider
Providers may be less inclined to order complex studies if you do not have a plan in place for follow up.
Great! The cost of a follow up virtual consultation appointment is $40. You can request it using this same form once your reports arrive.
Provider Name
*
*
I understand that the ordering physician does not have a way of knowing whether an ordered study is scheduled or its outcome.
Other Questions
Are you requesting a PET Scan?
*
Yes
No
STOP! PET Scans can not be ordered via our virtual consultation service. PET Scans are an advanced study that require the patient to be under the care of a physician.
Are you requesting a full body scan?
*
Yes
No
STOP! Full body scans can not be ordered via our virtual consultation service. These scans require the patient to be under the care of a primary care physician.
Medical Information
Do you have any of these allergies?
*
Radiation
Contrast
Dye
None
Which of these apply to you?
*
I take metformin
I have a kidney disease
I take NSAIDs such as ibuprofen, aleve, advil regularly
Pregnant
Breastfeeding
None
Select if you have any of these implanted devices
*
Heart pacemakers
Insulin pumps
Implanted hearing aids
Neurostimulators
Brain metal clips
Metal bone replacement
Others
No implanted devices
Current medications, including over the counter drugs
*
Answer none if not applicable
Are you allergic to any medications?
*
Answer none if not applicable
Any additional comments for the provider
Consent
*
I agree to the informed consent
I certify that the information I provided is complete, accurate and up-to-date to the best of my knowledge. I understand that incomplete, inaccurate or false information could result in harm from misdiagnosis and inappropriate treatment.
By continuing, I certify that I read (or had it read to me), and agree with your Informed Consent Agreement, Terms of Use and Privacy Policy, and that I am at least 18 years of age. I further understand that the telehealth provider who will see me in consultation is an independent healthcare professional who will abide by the best practice guidelines and all laws and regulations of the state medical board, and has no financial or other incentives to order any tests. Therefore, he/she may agree with the requested test if it is medically reasonable, suggest a different test, or not order any test if the request is not supported by your medical history.
Consent
*
I understand and agree to the following terms and limitations
This service has the following terms and limitations :
1. RadiologyAssist uses a third party tele-health service to provide consults. It does not employ or have any control over the providers actions or medical opinion.
2. Providers make referrals based on medical necessity guidelines. They could determine that an alternate type of study is needed or that imaging is not warranted at all. Your payment is for the consult and not its outcome. RadiologyAssist does not provide refunds for an unsatisfactory outcome.
3. RadiologyAssist makes no warranties that it is actually able to provide or schedule the imaging for an order written by the provider.
4. Your payment is for the service of consulting a medical professional. The payment does not include any implied guarantee that an order will be written or that RadiologyAssist will be able to schedule services recommended on any order that is written.
5. Any orders written as a result of a consult from this service are the property of the patient and can be used at any medical center including non-RadiologyAssist participating centers.
6. While we state usual turn around times, we do not guarantee any particular time-frame. If your need is urgent, please visit an ER. You may cancel your consultation request prior to receiving your consult at any time for a full refund. Once a consultation is completed, no refunds can be provided for any reason.
7. Referrals are issued based on the information provided by the patient. It is the patient's responsibility to review the written referral for accuracy before proceeding with scheduling any appointments. The issuing party or RadiologyAssist shall not be liable for any errors or omissions resulting from inaccurate or incomplete information provided by the patient.
Please certify
*
I certify that the information I provided is complete, accurate and up-to-date to the best of my knowledge. I understand that an incomplete, inaccurate and false information puts me at a harmful risk of misdiagnosis and inappropriate treatment. I also certify I have no cognitive impairment and am capable of making a sound medical decision
Payment
Virtual Consultation
Price:
$40.00
Async Consultation
Price:
$0.00
Total
$0.00
Credit Card
*
Only Mastercard, Visa and Discover accepted
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Date
Security Code
Cardholder Name
Billing Address
*
Same as patient address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
I authorize RadiologyAssist to charge my card in the amount specified above and I agree to RadiologyAssists
Payment Terms
and
Refund Policy
.
Note : For minors, the signature must be of the legal guardian.
Signature
*
Payer ID
Purchase Summary
Virtual Consult
$40.00
Total
$40.00
Page load link
Go to Top