Nationwide Access To Affordable Imaging

2100 Valley View Ln #490, Farmers Branch TX 75234 | Phone : 1-855-346-5152 | Fax : 1-855-345-5222

Refer a patient

For providers only.
Please use this form to submit an eReferral. RadiologyAssist will reach out to the patient for scheduling.
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.

Already have an order?

Fax Referral

Fax a completed referral to 855-345-5222.

Submit a referral using the secure upload form.

All-inclusive Rates Nationwide Rates starting from :
$265	MRI w/o contrast
$130	CT Scan w/o contrast
$140	Mammogram Screening or diagnostic
$115	Ultrasound Most Body Part
$33	X Ray 2 views