Refer a Patient (For providers only)

Please use this form to submit a Quick Referral. RadiologyAssist will reach out to the patient for scheduling.
You may alternatively sign up for our Provider Portal to refer and track your referrals and download reports.

Ordering Provider
Provider Name*
Data presented from NPI database. You can update the address on the next page.
Imaging Study
Imaging Study Being Ordered*
Please write name of study
- I am unable to find the imaging study needed
Diagnosis
Diagnosis
For lateral studies, which side?*
- Left
- Right
- Both (Bilateral)
- N/A
Additional Instructions
Additional instructions to include on order
These notes for the imaging center will be included at the bottom of the order.

Patient Information
Patient Name*
First Last
Date of birth*
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Address
Street Address Address Line 2 City State Zip Code
Phone*
Please ensure it is accurate and you are reachable at this number.
Email
Note to providers
Patients must be informed to call RadiologyAssist at 855-346-5152 to schedule their appointment
Provider Information
NPI
Please verify that provider data is accurate
Provider Name
First Last
Provider Address
Street Address Address Line 2 City State Zip Code
Provider Phone
Provider Fax*
Sign Order
Your Name*
Please certify*
- I certify under penalty of perjury under the laws of the United States of America that I am authorized to sign this electronic imaging order on behalf of the ordering provider
*
- Patient is aware about this referral and has been informed to call RadiologyAssist at 855-346-5152
Email
This field is for validation purposes and should be left unchanged.